Characterizing cognitive profiles in diverse middle-aged and older Hispanics/Latinos: Study of Latinos-Investigation of Neurocognitive Aging (HCHS/SOL)

Introduction

We investigated cognitive profiles among diverse, middle-aged and older Hispanic/Latino adults in the Study of Latinos-Investigation of Neurocognitive Aging (SOL-INCA) cohort using a cross-sectional observational study design.

Methods

Based on weighted descriptive statistics, the average baseline age of the target population was 56.4 years, slightly more than half were women (54.6%), and 38.4% reported less than a high school education. We used latent profile analysis of demographically adjusted z scores on SOL-INCA neurocognitive tests spanning domains of verbal memory, language, processing speed, and executive function.

Results

Statistical fit assessment indices combined with clinical interpretation suggested five profiles: (1) a Higher Global group performing in the average-to-high-average range across all cognitive and instrumental activity of daily living (IADL) tests (13.8%); (2) a Higher Memory group with relatively high performance on memory tests but average performance across all other cognitive/IADL tests (24.6%); (3) a Lower Memory group with relatively low performance on memory tests but average performance across all other cognitive/IADL tests (32.8%); (4) a Lower Executive Function group with relatively low performance on executive function and processing speed tests but average-to-low-average performance across all other cognitive/IADL tests (16.6%); and (5) a Lower Global group performing low-average-to-mildly impaired across all cognitive/IADL tests (12.1%).

Discussion

Our results provide evidence of heterogeneity in the cognitive profiles of a representative, community-dwelling sample of diverse Hispanic/Latino adults. Our analyses yielded cognitive profiles that may assist efforts to better understand the early cognitive changes that may portend Alzheimer's disease and related dementias among diverse Hispanics/Latinos.

Highlights

The present study characterized cognitive profiles among diverse middle-aged and older Hispanic/Latino adults.Latent profile analysis of neurocognitive test scores was the primary analysis conducted.The target population consists of middle-aged and older Hispanic/Latino adults enrolled in the Hispanic Community Health Study/Study of Latinos and ancillary Study of Latinos - Investigation of Neurocognitive Aging.

Developing and describing a typology of lucid episodes among people with Alzheimer's disease and related dementias

INTRODUCTION

This study examined lucid episodes among people living with late-stage Alzheimer's disease and related dementias (PLWD) and then developed a typology of these episodes to help characterize them.

METHODS

Family caregivers of PLWD provided information about witnessed episodes, including proximity to death, cognitive status, duration, communication quality, and circumstances prior to lucid episodes on up to two episodes (caregiver N = 151; episode N = 279). Latent class analysis was used to classify and characterize empirically distinct clusters of lucid episodes.

RESULTS

Four lucid episode types were identified. The most common type occurred during visits with family and among PLWD who lived > 6 months after the episode. The least common type coincided with family visits and occurred within 7 days of the PLWD's death.

DISCUSSION

Findings suggest that multiple types of lucid episodes exist; not all signal impending death; and some, but not all, are precipitated by external stimuli.

Dementia, dementia's risk factors and premorbid brain structure are concentrated in disadvantaged areas: National register and birth-cohort geographic analyses

INTRODUCTION

Dementia risk may be elevated in socioeconomically disadvantaged neighborhoods. Reasons for this remain unclear, and this elevation has yet to be shown at a national population level.

METHODS

We tested whether dementia was more prevalent in disadvantaged neighborhoods across the New Zealand population (N = 1.41 million analytic sample) over a 20-year observation. We then tested whether premorbid dementia risk factors and MRI-measured brain-structure antecedents were more prevalent among midlife residents of disadvantaged neighborhoods in a population-representative NZ-birth-cohort (N = 938 analytic sample).

RESULTS

People residing in disadvantaged neighborhoods were at greater risk of dementia (HR per-quintile-disadvantage-increase = 1.09, 95% confidence interval [CI]:1.08-1.10) and, decades before clinical endpoints typically emerge, evidenced elevated dementia-risk scores (CAIDE, LIBRA, Lancet, ANU-ADRI, DunedinARB; β's 0.31-0.39) and displayed dementia-associated brain structural deficits and cognitive difficulties/decline.

DISCUSSION

Disadvantaged neighborhoods have more residents with dementia, and decades before dementia is diagnosed, residents have more dementia-risk factors and brain-structure antecedents. Whether or not neighborhoods causally influence risk, they may offer scalable opportunities for primary dementia prevention.

Pain intensity, physical function, and depressive symptoms associated with discontinuing long-term opioid therapy in older adults with Alzheimer's disease and related dementias

INTRODUCTION

Limited evidence exists on the associations of discontinuing versus continuing long-term opioid therapy (LTOT) with pain intensity, physical function, and depression among patients with Alzheimer's disease and related dementias (ADRD).

METHODS

A cohort study among 138,059 older residents with mild-to-moderate ADRD and receipt of LTOT was conducted using a 100% Medicare nursing home sample. Discontinuation of LTOT was defined as no opioid refills for ≥ 60 days. Outcomes were worsening pain, physical function, and depression from baseline to quarterly assessments during 1- and 2-year follow-ups.

RESULTS

The adjusted odds of worsening pain and depressive symptoms were 29% and 5% lower at the 1-year follow-up and 35% and 9% lower at the 2-year follow-up for residents who discontinued versus continued LTOT, with no difference in physical function.

DISCUSSION

Discontinuing LTOT was associated with lower short- and long-term worsening pain and depressive symptoms than continuing LTOT among older residents with ADRD.

HIGHLIGHTS

Discontinuing long-term opioid therapy (LTOT) was associated with lower short- and long-term worsening pain. Discontinuing LTOT was related to lower short- and long-term worsening depression. Discontinuing LTOT was not associated with short- and long-term physical function.

Association of cancer history with structural brain aging markers of Alzheimer's disease and related dementias risk

INTRODUCTION

Cancer survivors are less likely than comparably aged individuals without a cancer history to develop Alzheimer's disease and related dementias (ADRD).

METHODS

In the UK Biobank, we investigated associations between cancer history and five structural magnetic resonance imaging (MRI) markers for ADRD risk, using linear mixed-effects models to assess differences in mean values and quantile regression to examine whether associations varied across the distribution of MRI markers.

RESULTS

Cancer history was associated with smaller mean hippocampal volume (b = -19 mm3 , 95% CI = -36, -1) and lower mean cortical thickness in the Alzheimer's disease signature region (b = -0.004 mm, 95% CI = -0.007, -0.000). Quantile regressions indicated individuals most vulnerable to ADRD were more affected by cancer history.

DISCUSSION

Some brain MRI markers associated with ADRD risk were elevated in adults with a history of cancer. The magnitude of the adverse associations varied across quantiles of neuroimaging markers, and the pattern suggests possible harmful associations for individuals already at high ADRD risk.

HIGHLIGHTS

We found no evidence of an inverse association between cancer history and ADRD-related neurodegeneration. Cancer history was associated with smaller mean hippocampal volume and lower mean cortical thickness in the Alzheimer's disease signature region. Quantile regressions indicated individuals most vulnerable to ADRD were more affected by cancer history.

Reality of Family Caregiving for Hispanics With Alzheimer's Disease and Related Dementias: A Qualitative Analysis

Background: Underserved Hispanic patients often experience unmet palliative care (PC) needs, particularly those with noncancer diagnoses such as Alzheimer's disease and related dementias. Most caregivers for Hispanic patients are family relatives who are less likely to use health care and community resources and experience high caregiver burden. We adapted a culturally tailored patient navigator (PN) intervention to provide support and improve PC outcomes for Hispanics with Alzheimer's disease and related dementias and their family caregivers (FCGs). Objectives: To explore Hispanic FCGs' experiences and perceptions of caregiving for a loved one, and how our PN intervention impacted their needs. Design: Qualitative descriptive. Setting/Subjects: FCG participants (n = 10) from our randomized control trial's intervention group were recruited from academic and safety net hospitals and community-based clinics across urban and rural Colorado in the United States. Measurements: Data obtained from individual, semistructured, 30-minute telephone interviews were recorded, transcribed, translated, and analyzed using NVivo and qualitative thematic analyses. Results: Four major themes emerged: Methods of Support, Cultural Expectations and Varying Family Contributions, Lack of Self-Care, and Awareness. Subthemes highlighted differing definitions of "contributing," role resentment, and interpersonal issues. Varying familial expectations underscore FCG strain when the burden of caregiving is not shared. Participants used various coping strategies as necessary support and gained awareness through education, guidance, and referrals to resources. Conclusions: PNs helped FCGs and patients beyond the intervention's scope. Providing support and awareness to FCGs, and incorporating cultural beliefs, may improve PC access to disparate populations and guide future interventions. Clinical Trial Registration Number NCT03181750.

Health care utilization and costs in the years preceding dementia identification

INTRODUCTION

There is evidence that health care utilization increases after incident dementia, particularly after dementia diagnosis and toward the end of life; however, less is known about utilization in the years before dementia identification.

METHODS

In this retrospective cohort study we obtained data on n = 5547 beneficiaries from the Health and Retirement Study (HRS)-Medicare linked sample (n = 1241 with and n = 4306 without dementia) to compare longitudinal trends in health care costs and utilization in the 6 years preceding dementia identification relative to a confounder-balanced reference group without dementia.

RESULTS

We found that persons with dementia had a greater prevalence of outpatient emergency department (ED), inpatient hospital, skilled nursing, and home health use, and total health care costs in the years preceding dementia identification compared to their similar counterparts without dementia across a comparable timespan in later life.

CONCLUSIONS

This study provides evidence to suggest greater healthcare burden may exist well before clinical manifestation and identification of dementia.

HIGHLIGHTS

Several studies have documented the tremendous healthcare-related costs of living with dementia, particularly toward the end of life. Dementia is a progressive neurodegenerative disease, which, for some, includes a prolonged pre-clinical phase. However, health services research to date has seldom considered the time before incident dementia. This study documents that health care utilization and costs are significantly elevated in the years before incident dementia relative to a demographically-similar comparison group without dementia.

Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes

BACKGROUND

Antipsychotic use is a safety concern among older patients in home health care (HHC), particularly for those with Alzheimer's disease and related dementias (ADRD). The objective of this study was to examine the prevalence and predictors of antipsychotic use among older adults with and without ADRD who received HHC, and the association of antipsychotic use with outcomes among patients living with ADRD.

METHODS

In this secondary analysis of adults ≥65 years receiving care from an HHC agency in New York in 2019 (N = 6684), we used data from the Outcome and Assessment Information Set, Medicare HHC claims, and home medication review results in the electronic HHC records during a 60-day HHC episode. ADRD was identified by diagnostic codes. Functional outcome was the change in the composite activities of daily living (ADL) score from HHC admission to HHC discharge (measured in 5833 patients), where a positive score means improvement and a negative score means decline. Data were analyzed using logistic (predictors) and linear regression (association with outcome) analyses.

RESULTS

The point prevalence of antipsychotic use was 17.2% and 6.6% among patients with and without ADRD, respectively. Among patients living with ADRD, predictors of antipsychotic use included having greater ADL limitations (odds ratio [OR] = 1.30, p = 0.01), taking more medications (OR = 1.04, p = 0.02), having behavioral and psychological symptoms (OR = 5.26, p = 0.002), and living alone (OR = 0.52, p = 0.06). Among patients living with ADRD, antipsychotic use was associated with having less ADL improvement at HHC discharge (β = -0.70, p < 0.001).

CONCLUSIONS

HHC patients living with ADRD were more likely to use antipsychotics and to experience worse functional outcomes when using antipsychotics. Antipsychotics should be systematically reviewed and, if contraindicated or unnecessary, deprescribed. Efforts are needed to improve HHC patients' access to nonpharmacological interventions and to provide education for caregivers regarding behavioral approaches to manage symptoms in ADRD.

Neighborhood resources and risk of cognitive decline among a community-dwelling long-term care population in the U.S

Objective

To examine the associations between neighborhood resources (i.e., number of restaurants, recreation centers, or social services for seniors and persons with disability per land area) and cognitive decline among a community-dwelling long-term care population and whether they differ by baseline cognition status.

Study design

Prospective longitudinal cohort study.

Methods

We used a longitudinal dataset that assessed over a two-year period older adults receiving state-funded home- and community-based services in Michigan Metropolitan areas (N = 9,802) and applied nonlinear mixed models with a random intercept with Poisson distribution.

Results

Cognitively intact older adults were less likely to experience cognitive decline when they resided in resource-rich neighborhoods, compared to those cognitively intact but living in neighborhoods that lacked resources. But their cognitively impaired or dementia-diagnosed counterparts did not similarly benefit from living in neighborhoods with rich resources.

Conclusions

Neighborhood resources may be an important aspect of intervention to mitigate cognitive decline before older adults become cognitively impaired.

Technology-Based Interventions to Address Social Isolation and Loneliness Among Informal Dementia Caregivers: A Scoping Review

OBJECTIVE

Social isolation and loneliness are major public health concerns. Informal dementia caregivers are particularly vulnerable, as many are older adults themselves and at elevated risk of adverse mental and physical health outcomes. Technology-based interventions could offer accessible, affordable, and convenient solutions. A previous review included Internet-based supportive interventions for informal dementia caregivers published up to 2013; however, new publications, technological advances, and targeted outcomes justify conducting this scoping review. Here, we identified and synthesized recent technology-based interventions that addressed social isolation and loneliness among informal dementia caregivers.

DESIGN

Scoping review.

SETTING AND PARTICIPANTS

Informal dementia caregivers in the community.

METHODS

Following Arksey and O'Malley's scoping review framework, we conducted a systematic search of peer-reviewed studies across 6 databases within the last 11 years, including identifying research questions, selecting relevant studies, charting data, and summarizing results.

RESULTS

From the 2937 articles identified, 10 eligible studies were included in this review. The intervention type, format, and duration varied widely. Three categories of interventions to address social isolation and loneliness among informal dementia caregivers included technology-assisted peer support, newly developed Web-based multicomponent psychoeducational programs and platforms, and virtual adaptation and modification of existing programs. Predominantly qualitative evidence suggests that technology-based interventions have the potential to reduce feelings of loneliness and improve caregiver well-being. Quantitative evidence tends to be preliminary and inconclusive.

CONCLUSIONS AND IMPLICATIONS

The findings offer preliminary evidence for technology-based interventions to reduce or prevent social isolation and loneliness in informal dementia caregivers. Technology-based interventions addressing social isolation and loneliness in informal dementia caregivers have the potential to overcome barriers to low uptake of services and withdrawal from interventions and improve the sustainability of the interventions. In the long run, by reducing or preventing social isolation and loneliness in informal dementia caregivers, the transition from home care to facility-based care might be delayed.

Self-Administered Gentle Yoga and Yoga Breathing Intervention Improves Burden and Stress Biomarkers in Caregivers of Persons Living with Dementia

Family caregivers of adults with Alzheimer's disease and related dementias (ADRD) are the fastest growing group of informal healthcare providers in the United States. These individuals experience high levels of stress and physical and psychosocial symptoms related to their caregiving role. We provided 20 ADRD caregivers (≥ 55 years of age) with training and access to a mobile health app for at-home practice of gentle yoga and yoga breathing exercises. Here, we report secondary outcomes, including changes in caregiver physical and mental function, burden, fatigue, sleep, and biological stress markers (salivary cortisol and 1,5-anhydroglucitol [1,5-AG] assays) from Baseline (Week 1) to Study End (Week 12). Self-reported questionnaire data were collected online via the Research Electronic Data Capture system, and biomarker data were collected via saliva samples. Results supported indications for slight improvement in outcomes of caregiving burden among ADRD caregivers using the gentle yoga and yoga breathing app. Furthermore, slight improvements in mental health were observed; the greatest gains were made by those reporting higher burden and having family members with more severe dementias. Findings indicate that those experiencing the greatest improvement in caregiver burden scores spent the most time doing gentle yoga and yoga breathing exercises. Salivary stress biomarkers moved in a favorable direction (decreased cortisol; increased 1,5-AG) among caregivers practicing the exercises most often. This is among the first studies of gentle yoga and yoga breathing exercises for relieving ADRD caregiver burden and the first we are aware of to incorporate stress biomarker measurement.

ADscreen: A speech processing-based screening system for automatic identification of patients with Alzheimer's disease and related dementia

Alzheimer's disease and related dementias (ADRD) present a looming public health crisis, affecting roughly 5 million people and 11 % of older adults in the United States. Despite nationwide efforts for timely diagnosis of patients with ADRD, >50 % of them are not diagnosed and unaware of their disease. To address this challenge, we developed ADscreen, an innovative speech-processing based ADRD screening algorithm for the protective identification of patients with ADRD. ADscreen consists of five major components: (i) noise reduction for reducing background noises from the audio-recorded patient speech, (ii) modeling the patient's ability in phonetic motor planning using acoustic parameters of the patient's voice, (iii) modeling the patient's ability in semantic and syntactic levels of language organization using linguistic parameters of the patient speech, (iv) extracting vocal and semantic psycholinguistic cues from the patient speech, and (v) building and evaluating the screening algorithm. To identify important speech parameters (features) associated with ADRD, we used the Joint Mutual Information Maximization (JMIM), an effective feature selection method for high dimensional, small sample size datasets. Modeling the relationship between speech parameters and the outcome variable (presence/absence of ADRD) was conducted using three different machine learning (ML) architectures with the capability of joining informative acoustic and linguistic with contextual word embedding vectors obtained from the DistilBERT (Bidirectional Encoder Representations from Transformers). We evaluated the performance of the ADscreen on an audio-recorded patients' speech (verbal description) for the Cookie-Theft picture description task, which is publicly available in the dementia databank. The joint fusion of acoustic and linguistic parameters with contextual word embedding vectors of DistilBERT achieved F1-score = 84.64 (standard deviation [std] = ±3.58) and AUC-ROC = 92.53 (std = ±3.34) for training dataset, and F1-score = 89.55 and AUC-ROC = 93.89 for the test dataset. In summary, ADscreen has a strong potential to be integrated with clinical workflow to address the need for an ADRD screening tool so that patients with cognitive impairment can receive appropriate and timely care.

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia

INTRODUCTION

Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD.

METHODS

Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month.

RESULTS

For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates.

DISCUSSION

APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD.

HIGHLIGHTS

For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

Evaluating non-pharmacological approaches to nursing home dementia care: A protocol

Background

The COVID-19 pandemic has underscored the daily challenges nursing home (NH) staff face caring for the residents living with Alzheimer's Disease and Related Dementias (ADRD). Non-pharmacological approaches are prioritized over off-label medication to manage the behavioral and psychological symptoms of ADRD. Yet, it is not clear how to best equip NH staff and families with the knowledge and strategies needed to provide non-pharmacological approaches to these residents.

Methods

This clustered randomized trial will compare team- and problem-based approaches to non-pharmacological ADRD care. The team-based approach includes core training for all NH staff using a common language and strategies to support continuity and sustainability. The problem-based approach capitalizes on the expertise of the professional healthcare providers to target issues that arise. A convergent mixed methods design will be used to examine (a) comparative effectiveness of the two approaches on long-term NH resident outcomes and (b) whether either approach is protective against the negative consequences of COVID-19. The primary outcome is the percentage of ADRD residents with off-label antipsychotic medication use, which will be evaluated with an intent-to-treat approach. Staff and family caregiver perspectives will be explored using a multiple case study approach.

Conclusion

This trial will be the first-ever evaluation of team- and problem-based approaches to ADRD care across multiple NHs and geographic regions. Results can provide health system leaders and policymakers with evidence on how to optimize ADRD training for staff in an effort to enhance ADRD care delivery.

Impact of pharmaceutical care integrated at a psychosocial intervention to reduce caregiver's burden in Alzheimer's disease or related dementias: Negative results at 18 months and difficulties to conduct PHARMAID RCT

Background

Psychosocial interventions for caregivers of patients with Alzheimer disease and relative dementias (ADRD) reported a caregiver burden improvement. Multicomponent intervention integrating pharmaceutical care has not yet been evaluated while ADRD patients and their caregivers are exposed to high risk of drug-related problems. The PHARMAID study aimed to assess the impact of personalized pharmaceutical care integrated to a psychosocial program on the burden of ADRD caregivers at 18 months.

Methods

The PHARMAID RCT was conducted between September 2016 and June 2020 [ClinicalTrials.gov: NCT02802371]. PHARMAID study planned to enroll 240 dyads, i.e. ADRD patients and caregivers, whose inclusion criteria were: outpatient with mild or major neurocognitive disorders due to ADRD, living at home, receiving support from a family caregiver. Three parallel groups compared a control group with two interventional groups: psychosocial intervention and integrated pharmaceutical care at a psychosocial intervention. The main outcome was the caregiver burden assessed by the Zarit Burden Index (ZBI, score range 0-88) at 18 months.

Results

Overall, 77 dyads were included (32% of the expected sample size). At 18 months, the mean ZBI scores were 36.7 ± 16.8 in the control group, 30.3 ± 16.3 for the group with psychosocial intervention, and 28.8 ± 14.1 in group with integrated pharmaceutical care at psychosocial intervention. No significant difference was demonstrated between the three groups (p = 0.326).

Conclusions

The findings suggest that PHARMAID program had no significant impact on caregiver burden at 18 months. Several limitations have been highlighted and discussed by the authors in order to formulate recommendations for further research.

"Been there, done that:" A grounded theory of future caregiver preparedness in former caregivers of parents living with dementia

BACKGROUND

Family caregivers offer essential support to persons living with dementia (PLWD). Providing care for more than one family member or close other across adulthood is becoming increasingly common, yet little is known about the ways that caregiving experiences shape caregiver preparedness. The current study presents a grounded theory of future caregiver preparedness in former caregivers of PLWD.

METHOD

A coding team (five coders and two auditors) used Consensual Qualitative Research and grounded theory techniques to analyze transcripts from 32 semi-structured interviews with midlife former caregivers of parents who died following advanced Alzheimer's disease and related dementias.

RESULTS

Qualitative analysis revealed two dimensions of future caregiver preparedness: caregiving confidence and caregiving insights. Narratives from caregiving experiences informed participants' descriptions of their future caregiver preparedness. Though some former caregivers described a positive (i.e., boosted or sustained) sense of caregiving confidence following care for their parents, others described a diminished (i.e., restricted or impeded) sense of confidence. Regardless of their confidence, all caregivers described specific caregiving insights related to one or more categories (i.e., caregiving self-conduct, care systems and resources, and relating with a care partner).

CONCLUSIONS

Preparedness for future caregiving following recent care for a PLWD varies: For some, past experiences appear to offer cumulative advantages in anticipating future care roles, whereas for others, past experiences may contribute to apprehension towards, or rejection of, future care roles. Entering new caregiving roles with diminished confidence may have negative consequences for caregivers' and care partners' wellbeing. Multidimensional assessment of future caregiver preparedness in former caregivers of PLWD may support development of resources for former caregivers entering new caregiving roles.

Effects of Part D Star Ratings on racial and ethnic disparities in health care costs

Background

Racial/ethnic minorities are less likely than non-Hispanic White (White) patients to be included in the Medicare Part D Star Ratings measure assessment due to the restrictive inclusion criteria for the measures.

Objective

This paper examined the effects of racial/ethnic disparities in the measure assessment in Part D Star Ratings on disparities in healthcare costs among patients with Alzheimer's disease and related dementias (ADRD).

Methods

This cross-sectional study analyzed 2017 Medicare data. Proportions of Beneficiaries with ADRD were categorized into the included and excluded groups based on the inclusion criteria for the calculation of medication adherence measures in Star Ratings. Outcomes included costs for medications, physician visits, emergency room (ER) visits, and total costs. A generalized linear model was employed to compare costs across racial/ethnic groups. To explore the differential disparities in healthcare costs between the 2 groups, interaction terms between dummy variables for being excluded from the measure calculation and racial/ethnic minorities were included in the models.

Results

The patterns of racial/ethnic disparities in healthcare costs found in this study were generally consistent with expectations, with some exceptions. For example, compared with White patients, in the hyperlipidemia cohort, the physician visit cost for Black patients among the included group was 31% lower (cost ratio or CR = 0.69, 95% CI = 0.67-0.72); in the hypertension cohort, the hospitalization cost for Blacks among the excluded group was 15% higher (CR = 1.15, 95% CI = 1.12-1.19). More importantly, exclusion from measurement assessments was associated with differential cost disparities. For example, compared with individuals included in the measure assessment for hypertension, the Black-White disparities in costs for hospitalization and total healthcare were 30% higher (CR = 1.30, 95% CI = 1.26-1.34), and 10% higher (CR = 1.10; 95% CI = 1.08-1.12), respectively, among the excluded group.

Conclusions

Medicare Part D Star Ratings may be associated with aggravated racial/ethnic disparities in healthcare costs in the Medicare Part D population.

Medicare Hospice Policy Changes and Beneficiaries' Rate of Live Discharge and Length-of-Stay

CONTEXT

The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act systemized audits of long hospice stays, and the 2016 two-tier payment system decreased daily reimbursement rates after 60 days of enrollment. Both aimed to reduce long stays.

OBJECTIVES

Examine how live discharge rates and length of stay changed in relation to the policies.

METHODS

We computed monthly hospice-level percent live discharges and length of stay using 2008-2019 Medicare hospice claims. We compared prepolicies trends and postpolicies trends overall, within Alzheimer's disease and related dementias (ADRD) patients, within lung cancer patients, and stratified by hospice ownership (for-profit vs. nonprofit/government-owned).

RESULTS

We included 10,539,912 and 10,453,025 episodes of care in the analytical samples for live discharge and length of stay analyses, respectively. Overall percent live discharges declined during the prepolicies period (-0.13 percentage-points per month, 95% CI: -0.14, -0.12), but exhibited no significant change during the postpolicies period. Trends were driven primarily by for-profits, with similar patterns within ADRD and lung cancer patients. Overall, mean length of stay increased over time, with greater rate of increase during the postpolicies period (0.41 days per month, 95% CI: 0.39, 0.42) compared to the prepolicies period (0.12 days per month, 95% CI: 0.10, 0.14). Length-of-stay increased faster among ADRD patients, but changed minimally for lung cancer patients.

CONCLUSION

Live discharge rates declined significantly during the prepolicies period, but plateaued after implementation of the policies, driven by changes in for-profits. However, the policies did not reduce length of stay, which increased at faster rates, suggesting that postpolicies excess live discharges were not restricted to long-stay patients.

Incorporation of concussion history as part of the LIfestyle for BRAin Health (LIBRA) modifiable factors risk score and associations with cognition in older former National Football League players

OBJECTIVE

Investigate associations between the LIfestyle for BRAin Health (LIBRA) risk score with odds of mild cognitive impairment (MCI) diagnosis and cognitive function, incorporating concussion history.

METHODS

Former National Football League (NFL) players (N = 1050; mean age = 64.8 ± 9.0-years) completed initial testing for integration of concussion history into LIBRA scores (i.e., modified-LIBRA) and completed the Brief Test of Adult Cognition by Telephone (BTACT). Modified-LIBRA score (including concussion history) associations with odds of MCI and cognitive dysfunction were assessed via logistic and linear regression.

RESULTS

The highest quartile LIBRA scores were six times more likely to have a diagnosis of MCI compared to the lowest quartile (OR = 6.27[3.61, 10.91], p < 0.001). Modified-LIBRA scores significantly improved model fit for odds of MCI above original LIBRA scores (χ² (1) = 7.76, p = 0.005) and accounted for a greater fraction of variance in executive function (ΔR²  = 0.02, p = 0.003) and episodic memory (ΔR²  = 0.02, p = 0.002).

CONCLUSIONS

Modified-LIBRA score, incorporating concussion history, may help monitoring risk status in former contact sport athletes, by targeting modifiable, lifestyle-related risk factors.

Providers' Perspectives on High-Quality Dementia Care in Long-Term Care

OBJECTIVES

To understand dementia care providers' perspectives on high-quality care for persons living with dementia (PLWD) in long-term care (LTC).

DESIGN

A qualitative study using a directed content analysis approach.

SETTING AND PARTICIPANTS

Nine national LTC dementia care providers.

METHODS

We facilitated 5 listening sessions centered around dementia care philosophies, models, and practices. Two researchers first mapped qualitative data to the Holistic Approach to Transformational Change (HATCh) model for dementia care using a directed content analysis approach. They then identified themes and subthemes emerging from the data using a conventional analysis approach. They coded data iteratively and solicited input from 3 additional researchers to reach consensus where needed. Member checks were performed to ensure the trustworthiness of the data during 2 follow-up listening sessions.

RESULTS

The 9 participants described the importance of understanding the experiences of PLWDs in order to provide high-quality dementia care and to deliver such care with the residents and their preferences as the focus. They emphasized experiential education as essential for families and all staff, regardless of role. They noted the need to balance safety with resident choice, as well as the corresponding need for facility leadership and regulators to support such choices. The listening sessions revealed areas to foster person-centered care for PLWD, but also highlighted barriers to implementing this philosophy in LTC settings.

CONCLUSIONS AND IMPLICATIONS

Emergent themes included care practices that center on resident preferences and are supported by staff with the experiential education and communication skills necessary to relate to and support PLWD. These findings provide contextual information for researchers seeking to identify and test interventions that reflect LTC providers' priorities for PLWD and emphasize the need to align research priorities with provider priorities.

Adapting the Connect-Home transitional care intervention for the unique needs of people with dementia and their caregivers: A feasibility study

AIMS

After leaving skilled nursing facilities (SNF), 20% of people with dementia (PWD) are re-hospitalized within 30 days. We assessed fidelity, acceptability, preliminary outcomes, and mechanisms of the Connect-Home ADRD transitional care intervention.

DESIGN

A feasibility study of Connect-Home ADRD.

METHODS

The Connect-Home intervention was adapted for dementia-specific needs. PWD and caregiver dyads in 2 SNFs received transitional care. Data sources included interviews with PWD and caregivers and a review of health records.

RESULTS

19 of 34 eligible dyads (56%) were enrolled. The intervention was feasible (components delivered for >84% of dyads) and acceptable (dyads rated it very helpful and not difficult to use). Connect-Home ADRD adaptations included in-home support to manage symptoms of dementia and unplanned events, such as transition to hospice.

IMPACT

Connect-Home ADRD is feasible, acceptable, and merits future research as an intervention to reduce rapid return to acute care following SNF stays.

"Now at least we have something to call it": Patient and care partner experiences receiving an amyloid PET scan

BACKGROUND

The primary objective of this paper was to examine perspectives and experiences of individuals with cognitive impairment who received an amyloid PET scan and their care partners, with regard to the process, logistics, and decision-making associated with receiving an amyloid PET scan and its results.

METHODS

Structured telephone interviews were conducted with 200 randomly sampled scan recipient/care partner dyads from the CARE IDEAS study. The audio-recorded, transcribed responses were analyzed using an inductive qualitative content analytic approach.

RESULTS

Participating individuals and care partners described their experiences in seeking a diagnosis for memory issues, including decision-making and logistics involved with receiving an amyloid PET scan. Participants discussed the factors contributing to their decision to seek a diagnosis for their memory issues and their hopes and expectations in completing the scan. Participants also described the trajectory of this process, and although some described relatively straightforward trajectories, others described problems associated with identifying appropriate providers and coordinating care across numerous providers to obtain a diagnosis for their memory issues. Participants described an additional challenge of physicians attributing cognitive decline to normal aging, rather than signs of a neurodegenerative disorder.

CONCLUSIONS

Findings shed light on the barriers and delays that individuals and care partners experience in connecting with physicians and obtaining a comprehensive evaluation for cognitive problems. Results from this study have implications for physicians who provide care to older adults, and specifically highlight the need for greater care coordination and clearer communication with and systems of referral for patients.

Rural and urban disparities in potentially preventable hospitalizations among US patients with Alzheimer's Disease and Related Dementias: Evidence of hospital-based telehealth and enabling services

We examined urban and rural disparities in potentially preventable hospitalizations (PPHs) among US patients with Alzheimer's Disease and Related Dementias (ADRD) and the use of telehealth post-discharge and enabling services as mediators. We merged 2017 100% Medicare Fee-For-Service (FFS) claims with the Medicare Beneficiary Summary File, along with population and hospital-based characteristics. Logistic regression models were employed to examine differences in PPHs by telehealth and enabling services. The rates of PPHs related to acute and chronic conditions for patients with ADRD living in rural and micropolitan areas were significantly higher compared to patients with ADRD in urban areas. Telehealth post-discharge combined with enabling services significantly decreased the odds of PPHs associated with acute (OR: 0.93, 95% CI: 0.89-0.98, P-value <0.01) and chronic conditions (OR: 0.96, 95% CI: 0.92-1.00, P-value = 0.07). In addition, telehealth post-discharge combined with enabling services significantly decreased the odds of PPHs in patients with ADRD in rural (acute PPHs OR: 0.56, 95% CI: 0.41-0.77, P-value <0.01; chronic PPHs OR: 0.73, 95% CI: 0.55-0.97, P-value = 0.03) and micropolitan (acute PPHs OR: 0.65, 95% CI: 0.57-0.73, P-value <0.01; chronic PPHs OR: 0.83, 95% CI: 0.74-0.93, P-value <0.01) areas. Our results suggest that the combinations of telehealth post-discharge and enabling services are important interventions in helping to reduce preventable hospitalizations among patients with ADRD living in rural and micropolitan areas.

Memory care reduces nursing home admissions among assisted-living residents with dementia

INTRODUCTION

We compare nursing-home and hospital admissions among residents with Alzheimer's disease and related dementias (ADRD) in memory-care assisted living to those in general assisted living.

METHODS

Retrospective study of Medicare beneficiaries with ADRD in large (>25 bed) assisted-living communities. We compared admission to a hospital, to a nursing home, and long-term (>90 day) admission to a nursing home between the two groups, using risk differences and survival analysis.

RESULTS

Residents in memory-care assisted living had a lower adjusted risk of hospitalization (risk difference = -1.8 percentage points [P = .014], hazard ratio = 0.93 [0.87-1.00]), a lower risk of nursing-home admission (risk difference = -2.2 percentage points [P < .001], hazard ratio = 0.87 [-.79-0.95]), and a lower risk of a long-term nursing home admission (risk difference = -1.1 percentage points [P < .001], hazard ratio = 0.71 [0.57-0.88]).

DISCUSSION

Memory care is associated with reduced rates of nursing-home placement, particularly long-term stays, compared to general assisted living.

Association of Medicare bundled payment model with joint replacement care for people with dementia

BACKGROUND

We examined whether the Comprehensive Care for Joint Replacement (CJR) model was associated with changes in the receipt of joint replacement among people with Alzheimer's disease and related dementias (ADRD) as well as spending, health service use, and postsurgical outcomes among people with ADRD who underwent a joint replacement surgery.

METHODS

Retrospective cohort study using 2013-2017 Medicare claims and Minimum Data Set. We used a difference-in-differences analysis to compare people with ADRD residing in CJR-participating treatment areas versus nonparticipating control areas on the receipt of joint replacement, episode spending during the index hospitalization and subsequent 90-day post-discharge period, discharges to an institutional post-acute care setting, and readmissions within 90 days of hospital discharge.

RESULTS

Our sample included 3,361,950 Medicare enrollees with ADRD (2,156,995 women [64%]; mean [SD] age, 83 [8.0] years; 2,646,405 white [78%], 344,478 black [10%], 224,010 Hispanic [7%]). The receipt of replacement among people with ADRD changed similarly between CJR-participating treatment and control areas after CJR model was implemented, suggesting no association of CJR model with the receipt of replacement. Among people with ADRD who received joint replacement, the CJR model was associated with a $1029 decrease in spending per episode (95% confidence interval [CI] -$1577, -$481, p < 0.001), a 1.62 percentage point decrease in discharges to an institutional post-acute care setting (95% CI -3.17, -0.07, p = 0.04), but no changes in 90-day readmission (95% CI -2.68, 0.00, p = 0.051).

CONCLUSIONS

Despite concerns that the CJR model could hinder people with ADRD from receiving joint replacement, the receipt of joint replacement did not change among people with ADRD under CJR. The CJR model was associated with decreased spending for people with ADRD who received joint replacements, driven by reduced discharges to an institutional post-acute care setting, without any changes in 90-day readmission.

Global and regional projections of the economic burden of Alzheimer's disease and related dementias from 2019 to 2050: A value of statistical life approach

BACKGROUND

The burden of Alzheimer's disease and related dementias (ADRDs) is expected to grow rapidly with population aging, especially in low- and middle-income countries, in the next few decades. We used a willingness-to-pay approach to project the global, regional, and national economic burden of ADRDs from 2019 to 2050 under status quo.

METHODS

We projected age group and country-specific disability-adjusted life years (DALYs) lost to ADRDs in future years based on historical growth in disease burden and available population projections. We used country-specific extrapolations of the value of a statistical life (VSL) year and its future projections based on historical income growth to estimate the economic burden - measured in terms of the value of lost DALYs - of ADRDs. A probabilistic uncertainty analysis was used to calculate point estimates and 95% uncertainty bounds of the economic burden.

FINDINGS

In 2019, the global VSL-based economic burden of ADRDs was an estimated $2.8 trillion. The burden was projected to increase to $4.7 trillion (95% uncertainty bound: $4 trillion-$5.5 trillion) in 2030, $8.5 trillion ($6.8 trillion-$10.8 trillion) in 2040, and $16.9 trillion ($11.3 trillion-$27.3 trillion) in 2050. Low- and middle-income countries (LMICs) would account for 65% of the global VSL-based economic burden in 2050, as compared with only 18% in 2019. Within LMICs, upper-middle income countries would carry the largest VSL-based economic burden by 2050 (92% of LMICs burden and 60% of global burden).

INTERPRETATION

ADRDs have a large and inequitable projected future VSL-based economic burden.

FUNDING

The Davos Alzheimer's Collaborative.

Helping the Helpers - A research protocol for user-centered technology to aid caregiver management of medications for people with Alzheimer's disease and related dementias

BACKGROUND AND OBJECTIVE

Systematically supporting caregiver-assisted medication management through IT interventions is a critical area of need toward improving outcomes for people living with ADRD and their caregivers, but a significant gap exists in the evidence base from which IT interventions to support caregivers' medication tasks can be built. User-centered design can address the user needs evidence gap and provide a scientific mechanism for developing IT interventions that meet caregivers' needs. The present study employs the three phases of user-centered design to address the first two stages of the NIH Stage Model for Behavioral Intervention Development.

METHODS

We will conduct a three-phase study employing user-centered design techniques across three aims: Aim 1) assess the needs of ADRD caregivers who manage medications for people with ADRD (Stage 0); Aim 2) co-design a prototype IT intervention to support caregiver-assisted medication management collaboratively with ADRD caregivers (Stage IA); and Aim 3) feasibility test the prototype IT intervention with ADRD caregivers (Stage IB).

DISCUSSION

Our user-centered design protocol provides a template for integrating the three phases of user-centered design to address the first two stages of the NIH Stage Model that can be used broadly by researchers who are developing IT interventions for ADRD caregivers.

Increasing engagement of Hispanics/Latinos in clinical trials on Alzheimer's disease and related dementias

Introduction

Despite evidence that Hispanic/Latino populations are 1.5 times more likely than non-Latino Whites to develop Alzheimer's disease and related dementias (ADRD), Latinos are underrepresented in clinical trials testing treatments for ADRD. Data are needed on facilitators of ADRD clinical trial participation in Latinos. We leveraged in-depth qualitative methods to elucidate barriers and facilitators to participating in ADRD clinical trials in a large and diverse sample of Latinos; and to provide timely and actionable strategies to accelerate representation of Latinos in clinical trials on ADRD.

Methods

Data were collected in California between January 2019 and June 2020 from 25 focus groups (FGs): eight with Latino adults ages 18 to 49 (n = 54), nine with Latino adults ages 50+ (n = 75), and eight with caregivers of Latino older adults with ADRD (n = 52). Twelve community-based organization administrators were also interviewed. Transcripts of FGs and interviews were entered into Atlas.ti software. Three independent team members analyzed the transcripts with inductive/deductive qualitative content analysis. We triangulated data from stakeholder groups across sites, we used collaborative coding, and used the Consolidated Criteria for Reporting Qualitative Research.

Results

An overarching theme was a tension between wanting to learn more about ADRD and to participate in ADRD research but having limited awareness and opportunity. Five themes were identified: (1) remaining in limbo, (2) wanting information about ADRD, (3) wanting information on research about ADRD, (4) clearing researchers through trusted local organizations, and (5) practicing altruism through engagement in research opportunities.

Discussion

To increase representation of Latino communities in clinical trials on ADRD, bilingual information and education on ADRD and clinical trials needs to be better disseminated. Also, working with trusted local, regional, and national organizations can increase participation. Importantly, Latino participation can increase when research teams demonstrate altruistic actions and inform participants of public health reasons requiring their involvement.

HIGHLIGHTS

Participation in clinical trials on Alzheimer's disease and related dementias (ADRD) is limited among Latinos/Hispanics.Knowing the high prevalence of ADRD in Latinos increases willingness to participate.Observing altruism from researchers increases willingness to participate.Invitations from multiple organizations increases willingness to participate.Researchers should include public health reasons requiring Latinos' involvement.

Economic costs of dementia in 11 countries in Europe: Estimates from nationally representative cohorts of a panel study

Background

With population aging, the economic burden of dementia is growing in Europe. Understanding the economic costs of dementia provides an important basis for prioritization in public health policy and resource allocation.

Methods

We calculate the economic costs of dementia, including both direct medical and social care costs and indirect costs of informal care, for 11 countries in Europe. Costs are estimated using population-representative data from the Survey of Health, Ageing, and Retirement in Europe from 2004 to 2017, supplemented with external information about wages of care workers, dementia prevalence, and fraction of direct costs paid by other sources. We report overall costs for persons, both living and deceased with dementia and also isolate the costs attributable to dementia by estimating regression models that relate a given cost component to dementia while controlling for coexisting conditions and demographics. We make the monetary data comparable by adjusting for inflation and Purchasing Power Parity to 2018 euros.

Findings

Average annual direct out of pocket costs that can be attributed to dementia vary between EUR 253(95% CI: -17 to 522) and EUR 859 (95% CI: -587 to 2306) across countries, but are not statistically significant after adjustment for multiple testing. Average annual hours of informal care that can be attributed to dementia vary between 163 (95% CI: 27-299) and 1051 (95% CI: 15-2086) annual hours across countries, and are statistically significant in all countries before adjustment for multiple testing, and in seven out of 11 countries after this adjustment. Combining these estimates with external wage information in each country implies a burden between EUR 2687.4 (95% CI: 704.5 to 4670.3) and EUR 15,468 (95% CI: 8088.1 to 22,847.9) per individual with dementia per year depending on the country. When combined with external estimates of the fraction of direct costs covered by other payment sources (insurance, government) and numbers of individuals with dementia, estimates of the total costs of dementia at the country level vary from EUR 162.9 million (95% CI: 56.3 to 269.5) in Estonia to EUR 32,606.9 (95% CI: 13,893.9 to 51,319.9) in Germany. Informal care costs account for the largest proportion of costs attributable to dementia in all European countries, varying between about 50% and about 90%.

Interpretation

The economic burden of dementia on families in terms of direct out-of-pocket and informal care costs varies greatly by country, depending on the health and social care systems. Informal care costs accounts for the largest proportion of costs, requiring policy attention to dementia care provision and costs.

Funding

This project is funded by the National Institute on Aging, National Institutes of Health, USA (R01 AG030153).

Caregiver appraisals of lucid episodes in people with late-stage Alzheimer's disease or related dementias

INTRODUCTION

Little is known about how family caregivers who witness unexpected and spontaneous communication among people in late stages of Alzheimer's disease and related dementias (ADRD) appraise these episodes of lucidity (EL).

METHODS

In an electronic, cross-sectional survey for former and current caregivers who participate in UsAgainstAlzheimer's A-LIST^®, participants who reported witnessing an EL were asked how positive and stressful ELs were, if they made or changed decisions based on an EL, and what resources they sought out to explain ELs.

RESULTS

Caregivers reported 72% of ELs to be quite a bit or very positive, 17% to be stressful, and 10% to be both stressful and positive. Twelve percent of caregivers changed care plans because of ELs and 13% sought out information about ELs.

DISCUSSION

These exploratory data suggest caregiver reactions to EL vary. Caregivers may change or postpone care decisions due to EL, and few resources exist to address caregiver queries about EL.

Pain and the Alzheimer's Disease and Related Dementia Spectrum in Community-Dwelling Older Americans: A Nationally Representative Study

CONTEXT

Pain is a significant concern among older adults with Alzheimer's disease and related dementias (ADRD).

OBJECTIVES

Examine the association between cognitive impairment across the ADRD spectrum and pain assessment and treatment in community-dwelling older Americans.

METHODS

This cross-sectional, population-based study included 16,836 community-dwelling participants ≥ 50 years in the 2018 Health and Retirement Study. ADRD, assessed by validated cognitive measures, was categorized into "dementia," "cognitive impairment, no dementia (CIND)" and "intact cognition." Pain assessment included pain presence (often being troubled with pain), pain severity (degree of pain most of the time [mild/moderate/severe]), and pain interference (pain making it difficult to do usual activities). Pain treatment included recent use of over-the-counter pain medications and opioids (past 3 months), and regular intake of prescriptions for pain.

RESULTS

Dementia were associated with lower likelihood of reporting pain presence (Odds Ratio [OR]= 0.61, P = 0.01), pain interference (OR = 0.46, P < 0.001), reporting lower pain severity (e.g., moderate vs. no: Relative Risk Ratio = 0.38, P < 0.001), and lower likelihood of receiving pain treatment, that is, recent use of over-the-counter pain medications (OR = 0.60, P = 0.02) and opioids (OR = 0.33, P < 0.001), and regular intake of prescriptions for pain (OR = 0.461, P = 0.002). CIND was associated with reporting lower pain severity (e.g., moderate vs. no: Relative Risk Ratio = 0.75, P = 0.021), lower likelihood of reporting pain interference (OR = 0.79, P = 0.045) and recent over-the-counter pain medication use (OR = 0.74, P = 0.026).

CONCLUSION

CIND and dementia increased the risk of under-report and under-treatment of pain. Systematic efforts are needed to improve pain recognition and treatment among older adults with cognitive impairment, regardless of dementia diagnosis.

The Georgia Memory Net: Implementation of a statewide program to diagnose and treat Alzheimer's disease and related dementias

Objectives

The number of people living with dementia is growing and most patients go years without receiving a specific diagnosis or support services, leading to suboptimal care, negative impacts on the quality of life, and increased costs of care. To address these gaps, the State of Georgia Department of Human Services collaborated with academic and community partners to create the Georgia Memory Net (GMN).

Design

GMN is a hub and spoke model partnered with Emory University's Cognitive Neurology Clinic and Emory Goizueta Alzheimer's Disease Research Center to provide training and support for best practices in diagnosis and management to Memory Assessment Clinics (MACs) throughout the state.

Setting

Communities across the State of Georgia.

Participants

GMN is a mix of academic and community providers, hospital systems, state and community agencies. Patients and families are evaluated at the MACs and connected to community services.

Intervention

A dedicated clinic workflow: primary care providers (PCPs) identify a memory problem and refer to the MACs for diagnostic evaluation; meeting with a community services educator, and development of a care plan. The patient is reconnected with the PCP for continuity of care.

Measurements

Initial metrics include numbers of unique patients, total patient visits, and referrals to state agency partners for community services.

Results

GMN established five MACs across Georgia with annual state funding. Partners at Emory University provided initial training; refined patient workflows for best practices; and provide ongoing support, guidance, and continuing education for MAC teams. Local PCPs and community services partners demonstrated strong engagement with the new model.

Conclusions

GMN is an innovative care model to improve access to accurate and timely diagnosis in patients with memory loss. GMN may help improve the quality of life for patients and families through preventive and early care.

Using smartphone technology to improve prospective memory functioning: A randomized controlled trial

BACKGROUND

A decline in the ability to perform daily intentions-known as prospective memory-is a key driver of everyday functional impairment in dementia. In the absence of effective pharmacological treatments, there is a need for developing, testing, and optimizing behavioral interventions that can bolster daily prospective memory functioning. We investigated the feasibility and efficacy of smartphone-based strategies for prospective memory in persons with cognitive impairment.

METHODS

Fifty-two older adults (74.79 ± 7.20 years) meeting diagnostic criteria for mild cognitive impairment or mild dementia were enrolled in a 4-week randomized controlled trial. Participants were trained to use a digital voice recorder app or a reminder app to off-load prospective memory intentions. Prospective memory was assessed using experimenter-assigned tasks (e.g., call the laboratory on assigned days), standardized questionnaires, and structured interviews. Secondary dependent measures included days of phone and app usage, acceptability ratings, quality of life, and independent activities of daily living.

RESULTS

Participant ratings indicated that the intervention was acceptable and feasible. Furthermore, after the four-week intervention, participants reported improvements in daily prospective memory functioning on standardized questionnaires (p < 0.001, η_p²  = 0.285) and the structured interview (p < 0.001, d = 1.75). Participants performed relatively well on experimenter-assigned prospective memory tasks (51.7% ± 27.8%), with performance levels favoring the reminder app in Week 1, but reversing to favor the digital recorder app in Week 4 (p = 0.010, η_p²  = 0.079). Correlational analyses indicated that greater usage of the digital recorder or reminder app was associated with better prospective memory performance and greater improvements in instrumental activities of daily living (completed by care partners), even when controlling for condition, age, baseline cognitive functioning, and baseline smartphone experience.

CONCLUSIONS

Older adults with cognitive disorders can learn smartphone-based memory strategies and doing so benefits prospective memory functioning and independence.

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.

Knowledge and attitude towards Alzheimer's disease and related dementias in a low- to middle-income country: a cross-sectional survey among Lebanese middle-aged and older adults

BACKGROUND

Despite the growing burden of Alzheimer's disease and related dementias (ADRD) in low- to middle-income countries (LMICs) and prior findings of important gaps in research on ADRD knowledge, very few studies have assessed ADRD knowledge in these populations. This study evaluates the knowledge and attitudes towards ADRD among Lebanese middle-aged and older adults.

METHOD

Participants aged ≥ 40 (n = 215) attending primary care clinics at a large medical centre in Lebanon completed the Alzheimer's Disease Knowledge Scale (ADKS), an attitude scale, and the Duke University Religion Index.

RESULTS

ADRD knowledge accuracy was 61.5% (mean score = 18.6 out of 30 (SD = 3.05)). Items with the least correct answers were related to caregiving and risk factors (≤9% and ≤28%). Overall, participants had tolerant views concerning ADRD; the least positive views were regarding living with people with ADRD. Older age, lower educational attainment, and higher religiosity scores were associated with poorer knowledge and attitudes.

CONCLUSION

Results highlight the need for awareness and preventive efforts that address misconceptions about modifiable risk factors and living with ADRD, especially given that the burden of caregiving for older adults often falls on family members in Lebanon and other LMIC countries.

Sleep in Persons Living with Alzheimer's Disease and Related Dementias

Over a typical lifespan, the amount of time people spend each day sleeping decreases. Sleep patterns also change as people age. Sleep disorders are common among persons of all ages, and older adults are particularly vulnerable. Development of age-related neurodegenerative diseases, such as Alzheimer's disease and related dementias, is associated with pronounced sleep disruption. This article provides evidence-based guidelines for diagnosis and clinical management of sleep disorders that occur during the course of treatment of Alzheimer's disease and related dementias. The article presents novel interventions and future directions for clinical practice and sleep research, and addresses diversity and inclusivity.

Pain treatment and functional improvement in home health care: Relationship with dementia

BACKGROUND

Pain management is important to post-acute functional recovery, yet older persons with Alzheimer's disease and related dementias (ADRD) are often undertreated for pain. The main objectives were (1) to examine the relationship between ADRD and analgesic use among Medicare home health care (HHC) recipients with daily interfering pain, and (2) to examine the impact of analgesic use on functional outcome in patients with and without ADRD.

METHODS

We analyzed longitudinal data from the Outcome and Assessment Information Set, Medicare HHC claims, and HHC electronic medical records during a 60-day HHC episode. The sample included 6048 Medicare beneficiaries ≥65 years receiving care from an HHC agency in New York in 2019 who reported daily interfering pain. Analgesic use was assessed during HHC medication reconciliation and included any analgesic, non-opioid analgesic, and opioid. ADRD was identified from ICD-10 codes (HHC claims) and cognitive impairment symptoms (Outcome and Assessment Information Set [OASIS]). Functional outcome was measured as change in the composite Activity of Daily Living (ADL) limitation score in the HHC episode.

RESULTS

ADRD was related to a lower likelihood of using any analgesic (odds ratio [OR] = 0.66, 95% confidence interval [CI]: 0.49, 0.90, p = 0.008) and opioids (OR = 0.54, 95% CI: 0.47, 0.62, p < 0.001), but not related to non-opioid analgesic use (OR = 0.94, 95% CI: 0.74, 1.18, p = 0.58). Stratified analyses showed that any analgesic use (β = -0.43, 95% CI: -0.73, -0.13, p = 0.004) and non-opioid analgesic use (β = -0.31, 95% CI: -0.56, -0.06, p = 0.016) were associated with greater ADL improvement in patients with ADRD, but not in patients without ADRD. Opioid use was not significantly related to ADL improvement regardless of ADRD status.

CONCLUSIONS

HHC patients with ADRD may be undertreated for pain, yet pain treatment is essential for functional improvement in HHC. HHC clinicians and policymakers should ensure adequate pain management for older persons with ADRD for improved functional outcomes.

Live hospice discharge: Experiences of families, and hospice staff

OBJECTIVE

To examine live hospice discharge prevalence and experiences of families and hospice staff. Hospice eligibility is based on a cancer model where decline and death are predicable. Decline is less predictable for diagnoses such as dementia, frequently resulting in involuntary live hospice discharge.

METHODS

A mixed-method integration of hospice 2013-17 admission/discharge data, 5 family interviews, hospice discipline-specific focus groups (3 aides, 2 nurses, 1 administrator interview) and a discipline-combined focus group (all 6 staff; each staff participant engaged in two data collection experiences).

RESULTS

5648 hospice admissions occurred between 2013-17; 795 patients experienced live discharge. The most prevalent admitting diagnosis was cancer, the most prevalent live discharge diagnosis was dementia. Family caregiver themes were Attitude and experience with hospice, Discharge experience, and Continued need/desire for hospice following discharge. Staff themes were Discharge circumstances, Regulatory guidelines, and Changing practice to meet regulatory guidelines.

CONCLUSION

Involuntary live hospice discharge precludes patient-centered care due to policy constraints, especially for those with noncancer diagnoses. Families and staff noted the paradox of beneficial hospice care, yet this care resulted in ineligibility for continued hospice services.

PRACTICE IMPLICATIONS

Transparent, patient-family-staff communication (including CNAs) facilitates hospice live discharge planning. Hospice service eligibility policy changes are needed.

Asian Americans and Pacific Islanders' perspectives on participating in the CARE recruitment research registry for Alzheimer's disease and related dementias, aging, and caregiving research

INTRODUCTION

This study elicited Asian Americans and Pacific Islanders' (AAPI) perspectives about recruitment strategies/messaging for participation in an aging, Alzheimer's disease and related dementias (ADRD), and caregiving research recruitment registry.

METHODS

Using a mixed methods design, CARE (Collaborative Approach for AAPI Research and Education) conducted 14 focus groups (N = 123) with AAPI cultural groups (Asian Indian, Chinese, Filipino, Japanese, Korean, Samoan, Vietnamese) in different languages. Descriptive statistics and thematic qualitative analyses were conducted.

RESULTS

Mean age of participants was 54 years (median: 61; range 18-80), 66% were female, and 81% were foreign-born. Themes of consideration for recruitment emerged: (1) culturally/linguistically appropriate outreach in culturally specific spaces, (2) motivations for research participation, and (3) approaches to outreach and recruitment methods. Within each of these themes, there were ethnic differences in specific strategies/approaches reflected as subthemes.

DISCUSSION

Recruitment and messaging strategies should be tailored uniquely for each targeted AAPI group, with a thorough understanding of the cultural/linguistic factors that facilitate research participation to increase AAPI participation in ADRD, aging, and caregiver-related research. .

Using poetry as data to explore daily and formal care decision making within African American dementia dyads

There is limited research exploring how daily and formal care decision making occurs within African American dementia dyads as well as how these dyads navigate decision making across the dementia trajectory. Through semi-structured interviews, five African American dementia dyads shared their decision-making processes. We used a multimethod approach to the analysis of data, including qualitative and quantitative content analysis and the creation of I Poems. This novel use of I Poems provided a uniquely personal account of the lived experiences of the African American persons living with dementia, while other analyses revealed that within dyads, daily care decision making was led by African American persons living with dementia, whereas formal care decision making varied between dyads. There was intra-dyad congruence regarding who the final decision maker was in daily and formal care. Clinicians and researchers may be able to tailor interventions based on the dyad's involvement in these decision-making processes.

Identifying prescribing cascades in Alzheimer's disease and related dementias: The calcium channel blocker-diuretic prescribing cascade

PURPOSE

Prescribing cascades occur when a physician prescribes a new drug to address the side-effect of another drug. Persons with Alzheimer's disease and related dementias (ADRD) are at increased risk for prescribing cascades. Our objective was to develop an approach to estimating the proportion of calcium channel blocker-diuretic (CCB-diuretic) prescribing cascades among persons with ADRD in two U.S. health plans.

METHODS

We identified patients aged ≥50 on January 1, 2017, dispensed a drug to treat ADRD in the 365-days prior to/on cohort entry date. Patients had medical/pharmacy coverage for 1 year before and through cohort entry. We excluded individuals with an institutional stay encounter in the 45 days prior to cohort entry and censored patients based on: disenrollment from coverage, death, or end of data. We identified incident and prevalent CCB use in the 183-days following cohort entry, and identified subsequent incident diuretic use among incident and prevalent CCB-users within 365-days from cohort entry.

RESULTS

There were 121 538 eligible patients. Approximately 62% were female, with a mean age of 79.5 (SD ±8.6). Overall 2.1% of the cohort experienced a prevalent CCB-diuretic prescribing cascade with 1586 incident diuretic-users among 36 462 prevalent CCB-users (4.3%, 95% CI 4.1-4.6%]); and there were161 incident diuretic-users among 3304 incident CCB-users (4.9%, 95% CI 4.2-5.7%) (incident CCB-diuretic cascade).

CONCLUSIONS

We describe an approach to identify prescribing cascades in persons with ADRD, which can be used to assess the proportion of prescribing cascades in large cohorts. We determined the proportion of CCB-diuretic prescribing cascades was low.

Music Compared with Auditory Books: A Randomized Controlled Study Among Long-Term Care Residents with Alzheimer's Disease or Related Dementia

BACKGROUND

Over 5 million Americans age 65 years and older were diagnosed with Alzheimer's disease and/or related dementia (ADRD), a majority of whom exhibit behavioral and psychological symptoms leading to placement in long-term care settings. These facilities need nonmedical interventions, and music-based programs have received supportive evidence.

SETTING

Thirteen long-term care facilities were among a wave of facilities that volunteered to be trained and to administer a music-based intervention. The residents within were randomized into intervention or control groups (intervention/music, n = 103; control/audiobook, n = 55).

DESIGN

This team used a pragmatic trial to randomly embed music and control (audiobooks) into 13 long-term care facilities to compare the effects on agitation in people with ADRD.

METHODS

Measures included a demographic survey; the Mini-Mental Status Examination, used to assess cognitive status; and the Cohen-Mansfield Agitation Inventory with 4 subscales, used to measure agitation. These measures were implemented at baseline and every 2 weeks for 8 weeks. Mixed-effects models were used to evaluate change in agitation measures while addressing dependencies of scores within participants and facility.

RESULTS

Decreases in agitation were attributable to both music and audiobooks in 3 of 4 agitation subscales. In the fourth, physical agitation, which was not directed toward staff, initially, it decreased given music, and increased thereafter; and generally, it increased with the audiobooks.

CONCLUSION AND IMPLICATIONS

Both music and control audiobooks delivered by headphones after personalized selection reduced some aspects of agitation in residents diagnosed with ADRD. The effects of music were greater initially then diminished.

Antidopaminergic-Antiparkinsonian Medication Prescribing Cascade in Persons with Alzheimer's Disease

OBJECTIVES

Persons living with Alzheimer's disease (AD) may be at increased risk for prescribing cascades due to greater multimorbidity, polypharmacy, and the need for more complex care. Our objective was to assess the proportion of the antidopaminergic-antiparkinsonian medication prescribing cascades among persons living with Alzheimer's disease.

SETTING

Two large administrative claims databases in the United States.

PARTICIPANTS

We identified patients aged ≥50 on January 1, 2017, who were dispensed a drug used to treat Alzheimer's disease for at least 1 day in the 365 days prior to or on cohort entry date and who had medical and pharmacy coverage in the 365 days prior to the cohort entry date. We excluded individuals with a recent institutional stay. We identified incident antidopaminergic (antipsychotic/metoclopramide) use in the 183 days following cohort entry and identified subsequent incident antiparkinsonian drug use within 8 to 365 days.

RESULTS

There were 121,538 patients with Alzheimer's disease eligible for inclusion. Approximately 62% were women with a mean age of 79.5 (SD ± 8.6). The mean number of drugs dispensed was 9.2 (SD ± 4.9). There were 36 incident antiparkinsonian users among 4,534 incident antipsychotic/metoclopramide users (0.8%).

CONCLUSION

We determined that the proportion of antidopaminergic-antiparkinsonian medication prescribing cascades, widely considered as high-priority, was low. Our approach can be used to assess the proportion of prescribing cascades in populations considered to be at high risk and to prioritize system-level interventional efforts to improve medication safety in these patients.

Accountable Care Hospitals and Preventable Emergency Department Visits for Rural Dementia Patients

BACKGROUND/OBJECTIVES

This study examined urban/rural differences in the frequency of preventable emergency department (ED) visits among patients with Alzheimer's disease and related dementias (ADRD), with a focus on the variation of accountable care organization (ACO) participation status for hospitals in urban and rural areas.

DESIGN

We performed a cross-sectional study using the 2015 State Emergency Department Databases, the American Hospital Association Annual Survey of Hospitals, and the Area Health Resource File. Individual-, county-, and hospital-level characteristics and state fixed effects were used for model specification.

SETTING

Patients with ADRD from seven states who visited the ED and had routine discharges.

PARTICIPANTS

Our sample consisted of 117,196 patients with ADRD.

MEASUREMENTS

The outcome was preventable ED visits classified using the New York University Emergency Department visit algorithm. We performed a multivariable logistic regression to estimate the variation of preventable ED visits by urban and rural areas.

RESULTS

Rural patients with ADRD had 1.13 higher adjusted odds (P = .007) of going to the ED for a preventable visit compared with their urban counterparts. In addition, ACO-affiliated hospitals had .91 lower adjusted odds (P = .005) of preventable ED visits for ADRD patients compared with hospitals not affiliated with an ACO. Whole-county Mental Health Care Health Professional Shortage Area (HPSA) (odds ratio = 1.14; P = .002) designation was also an indicator of higher preventable ED rates.

CONCLUSION

ACO delivery systems have the potential to decrease rural preventable ED visits among ADRD patients.

Quality of Post-Acute Care in Skilled Nursing Facilities That Disproportionately Serve Hispanics With Dementia

OBJECTIVES

As the number of Hispanics with dementia continues to increase, greater use of post-acute care in nursing home settings will be required. Little is known about the quality of skilled nursing facilities (SNFs) that disproportionately serve Hispanic patients with dementia and whether the quality of SNF care varies by the concentration of Medicare Advantage (MA) patients with dementia admitted to these SNFs.

DESIGN

Cross-sectional study using 2016 data from Medicare certified providers.

SETTING AND PARTICIPANTS

Our cohort included 177,396 beneficiaries with probable dementia from 8884 SNFs.

METHODS

We examined facility-level quality of care among facilities with high and low proportions of Hispanic beneficiaries with probable dementia enrolled in MA and fee-for-service (FFS) using data from Medicare-certified providers. Three facility-level measures were used to assess quality of care: (1) 30-day rehospitalization rate; (2) successful discharge from the facility to the community; and (3) Medicare 5-star quality ratings.

RESULTS

About 20% of residents were admitted to 1615 facilities with a resident population that was more than 15% Hispanic. Facilities with a higher share of Hispanic residents had a lower proportion of 4- or 5-star facilities by an average of 14% to 15% compared with facilities with little to no Hispanics. In addition, these facilities had a 1% higher readmission rate. There were also some differences in the quality of facilities with high (>26.5%) and low (<26.5%) proportions of MA beneficiaries. On average, SNFs with a high concentration of MA patients have lower readmission rates and higher successful discharge, but lower star ratings.

CONCLUSIONS AND IMPLICATIONS

Achieving better quality of care for people with dementia may require efforts to improve the quality of care among facilities with a high concentration of Hispanic residents.

Using Medicare claims in identifying Alzheimer's disease and related dementias

INTRODUCTION

This study develops a measure of Alzheimer's disease and related dementias (ADRD) using Medicare claims.

METHODS

Validation resembles the approach of the American Psychological Association, including (1) content validity, (2) construct validity, and (3) predictive validity.

RESULTS

We found that four items-a Medicare claim recording ADRD 1 year ago, 2 years ago, 3 years ago, and a total stay of 6 months in a nursing home-exhibit a pattern of association consistent with a single underlying ADRD construct, and presence of any two of these four items predict a direct measure of cognitive function and also future claims for ADRD.

DISCUSSION

Our four items are internally consistent with the measurement of a single quantity. The presence of any two items do a better job than a single claim when predicting both a direct measure of cognitive function and future ADRD claims.

Incremental Health Care Expenditures of the Spouses of Older Adults With Alzheimer's Diseases and Related Dementias (ADRD)

OBJECTIVE

Previous research has found that having a spouse with Alzheimer's disease and related dementias (ADRD) is associated with higher health care expenditures, however it is unclear if this difference remains after accounting for the demographics and health status of the non-ADRD spouse. This paper aims to estimate the adjusted incremental health care expenditures of having a spouse with ADRD.

DESIGN

Cross-sectional study of publicly available survey data (2003-2017 Medical Expenditure Panel Survey).

SETTING

Representative sample of U.S. households.

PARTICIPANTS

Community-dwelling and married older adults (n = 28,356).

MEASUREMENT

Two-part models and recycled prediction techniques to estimate the incremental effects of having a spouse with ADRD on annual health care expenditures, while adjusting for demographics, socioeconomic characteristics, and health conditions.

RESULTS

Spouses of older adults with ADRD were older, had worse perceived mental health, and had greater difficulties with activities of daily living, compared to older adults with cognitively normal spouses. Spouses of ADRD patients had significantly higher unadjusted total health care expenditures, however their adjusted incremental expenditure was not significantly greater. After controlling for demographics and health status, ADRD spouses had significantly higher home health care expenditures, but significantly lower outpatient expenditures.

CONCLUSION

Results suggested that the higher health care expenditures in older adults with ADRD spouses can be attributed to the higher rate of comorbidities, rate of functional limitations, and mean age in this group. The increased use of home health and decreased use of outpatient in this population suggests the importance of tailoring preventative health care and social services to meet the needs of this group.

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

OBJECTIVES

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

DESIGN

Retrospective observational national study.

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sources of Caregiving Burden in Middle-Aged and Older Latino Caregivers

OBJECTIVE

We aimed to identify sources of caregiver burden in middle-aged and older Latino caregivers of people with Alzheimer disease and related dementia (ADRD).

METHODS

Participants were recruited through an agreement with the Rush Alzheimer's Disease Center Clinic Data Repository. We conducted semistructured interviews with 16 middle-aged and older Latinos who were the primary caregiver for a family member diagnosed with ADRD. The interview guide consisted of questions and probes to capture participants' perceptions of family caregiving. Direct content analysis was performed.

RESULTS

Participants were aged 50 to 75 years (n = 16) and a majority female (n = 12). The sources of burden identified were (1) caregiver responsibilities, (2) caregiving-related health decline, (3) lack of support, (4) financial status, (5) vigilance, and (6) concerns about the future.

CONCLUSIONS

The influence of gender roles seemed to play a role in caregivers' perceptions of sources of burden, especially on caregiver responsibilities and perceptions of lack of support. Latinos cultural values such as familismo and marianismo likely reinforced gender disparities in family caregiving.