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

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.

Management of Neuropsychiatric Symptoms in Neurocognitive Disorders

Dementias, renamed neurocognitive disorders (NCDs) in the DSM-5, are defined by acquired decline in cognitive and functional abilities. DSM-5 now also includes mild NCD, which incorporates the previous diagnosis of mild cognitive impairment. DSM-5 recognizes the following etiologies for NCDs: NCD due to Alzheimer's disease, vascular NCD, NCD with Lewy bodies, frontotemporal NCD, substance-/medication-induced NCD, NCD due to traumatic brain injury, NCD due to Huntington's disease, NCD due to HIV infection, NCD due to prion disease, and NCD due to other medical conditions. In this review, the authors discuss a wide variety of interventions that have been studied for the treatment and management of neuropsychiatric symptoms of patients with NCDs. In addition to nonpharmacological interventions, several classes of medications-including antipsychotics, antidepressants, anticonvulsants, and cholinesterase inhibitors-have been studied for this indication.

Cholinesterase inhibitors do not alter the length of stay in nursing homes among patients with Alzheimer's disease: a prospective, observational study of factors affecting survival time from admission to death

BACKGROUND

The survival time in nursing homes (NHs) in Alzheimer's disease (AD) might be affected by sociodemographic/clinical characteristics, rate of disease progression, and use of specific medications and community-based services. Whether different aspects of cholinesterase inhibitor (ChEI) therapy modify time spent in NHs is unclear. Therefore, we examined the relationship between these potential predictors and survival time in NHs.

METHODS

This prospective, multicenter study of ChEI treatment in clinical practice included 220 deceased patients clinically diagnosed with mild-to-moderate AD who were admitted to NHs during the study. Cognitive and activities of daily living (ADL) performance, ChEI dose, and amount of services used/week were evaluated every 6 months over 3 years. Dates of nursing-home placement (NHP) and death were recorded. Variables that determined survival time in NHs were analyzed using general linear models.

RESULTS

The mean survival time in NHs was 4.06 years (men, 2.78 years; women, 4.53 years; P < 0.001). The multivariate model showed that a shorter stay in NHs was associated with the interaction term male living with a family member, use of antihypertensive/cardiac therapy or anxiolytics/sedatives/hypnotics, and worse basic ADL at NHP, but not with age or cognitive and instrumental ADL capacities.

CONCLUSIONS

Increased community-based care did not reduce the survival time in NHs among individuals with AD. Men living with family spent significantly less time in NHs compared with the corresponding women, which suggests that the situation of female spouses of AD patients may need attention and possibly support. There was no indication that different aspects of ChEI therapy, e.g., drug type, dose, or duration, alter survival time in NHs.

Risk Factors of Caregiver Burden Evolution, for Patients With Subjective Cognitive Decline or Neurocognitive Disorders: A Longitudinal Analysis

BACKGROUND/OBJECTIVES

The identification of factors used to predict caregiver burden may help preventive care. This study aimed to assess the relationship between evolution of patients with subjective cognitive decline (SCD) or progressive neurocognitive disorder (NCD) and evolution of caregiver burden.

DESIGN

Observational, longitudinal study.

SETTING

The study was conducted in the Clinical and Research Memory Center of the University Hospital of Lyon (France), between the November 1, 2011 and the June 30, 2014, with a maximum follow-up of 30 months.

PARTICIPANTS

The study population included outpatients with SCD or NCD at all stages, and their informal caregiver.

MEASUREMENTS

The caregiver burden was assessed during 2 visits of the patients and their caregiver, with the short version of the Zarit Burden Inventory (ZBI). Functional, cognitive performance, and behavioral and psychological symptoms were measured twice, concomitantly with the ZBI, using the Instrumental Activities of Daily Living (IADL) scale, the Mini-Mental State Examination (MMSE), and the Neuropsychiatric Inventory (NPI), respectively. Etiology and stage of the cognitive impairment were collected.

RESULTS

The population study included 222 patients (mean age at inclusion: 80 years old, 62.9% females), with an average follow-up 12.6 ± 6 months. Proportion of patients with major NCD at the second visit (62.2%) increased compared with inclusion (50.0%). MMSE and IADL decreased between the 2 visits (P < .001), whereas ZBI increased (mean ZBI: 3.2 ± 2 at baseline, mean ZBI: 3.8 ± 2 at follow-up, P < .001). In unadjusted analyses, ZBI tended to be higher for patients whose MMSE decreased of at least 3 points between the visits. ZBI increased over time when IADL decreased (P value for within-patient effect <.001), while it remained stable when the IADL increased. ZBI increased when NPI increased. After mutual adjustment for change of MMSE, IADL, NPI, and etiologies, increase of ZBI over time remained significant when MMSE decreased at least 3 points between baseline and follow-up, when IADL decreased, and when NPI increased of at least 4 points.

CONCLUSIONS

In a study population of patients with SCD or NCD at all stages, concomitant decrease of cognitive performance, increase of functional impairment, and increase neuropsychiatric symptoms over time were independently associated with increased caregiver burden. The identification of risk factors associated with an increased caregiver burden over time may allow a better evaluation of the impact of specific interventions on cognitive, behavioral, and functional dimensions of NCD on caregivers.

TRIAL REGISTRATION

ClinicalTrials.govNCT02825732.

Development and validation of clinical profiles of patients hospitalized due to behavioral and psychological symptoms of dementia

BACKGROUND

Patients hospitalized on acute psychogeriatric wards are a heterogeneous population. Cluster analysis is a useful statistical method for partitioning a sample of patients into well separated groups of patients who present common characteristics. Several patient profile studies exist, but they are not adapted to acutely hospitalized psychogeriatric patients with cognitive impairment. The present study aims to partition patients hospitalized due to behavioral and psychological symptoms of dementia into profiles based on a global evaluation of mental health using cluster analysis.

METHODS

Using nine of the 13 items from the Health of the Nation Outcome Scales for elderly people (HoNOS65+), data were collected from a sample of 542 inpatients with dementia who were hospitalized between 2011 and 2014 in acute psychogeriatric wards of a Swiss university hospital. An optimal clustering solution was generated to represent various profiles, by using a mixed approach combining hierarchical and non-hierarchical (k-means) cluster analyses associated with a split-sample cross-validation. The quality of the clustering solution was evaluated based on a cross-validation, on a k-means method with 100 random initial seeds, on validation indexes, and on clinical interpretation.

RESULTS

The final solution consisted of four clinically distinct and homogeneous profiles labeled (1) BPSD-affective, (2) BPSD-functional, (3) BPSD-somatic and (4) BPSD-psychotic according to their predominant clinical features. The four profiles differed in cognitive status, length of hospital stay, and legal admission status.

CONCLUSION

In the present study, clustering methods allowed us to identify four profiles with distinctive characteristics. This clustering solution may be developed into a classification system that may allow clinicians to differentiate patient needs in order to promptly identify tailored interventions and promote better allocation of available resources.

How to deal with missing longitudinal data in cost of illness analysis in Alzheimer's disease-suggestions from the GERAS observational study

Background

Missing data are a common problem in prospective studies with a long follow-up, and the volume, pattern and reasons for missing data may be relevant when estimating the cost of illness. We aimed to evaluate the effects of different methods for dealing with missing longitudinal cost data and for costing caregiver time on total societal costs in Alzheimer’s disease (AD).

Methods

GERAS is an 18-month observational study of costs associated with AD. Total societal costs included patient health and social care costs, and caregiver health and informal care costs. Missing data were classified as missing completely at random (MCAR), missing at random (MAR) or missing not at random (MNAR). Simulation datasets were generated from baseline data with 10–40 % missing total cost data for each missing data mechanism. Datasets were also simulated to reflect the missing cost data pattern at 18 months using MAR and MNAR assumptions. Naïve and multiple imputation (MI) methods were applied to each dataset and results compared with complete GERAS 18-month cost data. Opportunity and replacement cost approaches were used for caregiver time, which was costed with and without supervision included and with time for working caregivers only being costed.

Results

Total costs were available for 99.4 % of 1497 patients at baseline. For MCAR datasets, naïve methods performed as well as MI methods. For MAR, MI methods performed better than naïve methods. All imputation approaches were poor for MNAR data. For all approaches, percentage bias increased with missing data volume. For datasets reflecting 18-month patterns, a combination of imputation methods provided more accurate cost estimates (e.g. bias: −1 % vs −6 % for single MI method), although different approaches to costing caregiver time had a greater impact on estimated costs (29–43 % increase over base case estimate).

Conclusions

Methods used to impute missing cost data in AD will impact on accuracy of cost estimates although varying approaches to costing informal caregiver time has the greatest impact on total costs. Tailoring imputation methods to the reason for missing data will further our understanding of the best analytical approach for studies involving cost outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12874-016-0188-1) contains supplementary material, which is available to authorized users.

Cost of Dementia and Its Correlation With Dependence

Objective: To estimate the cost of dementia care and its relation to dependence. Method: Disease severity and health care resource utilization was retrieved from the Swedish National Study on Aging and Care. Informal care was assessed with the Resource Utilization in Dementia instrument. A path model investigates the relationship between annual cost of care and dependence, cognitive ability, functioning, neuropsychiatric symptoms, and comorbidities. Results: Average annual cost among patients diagnosed with dementia was €43,259, primarily incurred by accommodation. Resource use, that is, institutional care, community care, and accommodation, and corresponding costs increased significantly by increasing dependency. Path analysis showed that cognitive ability, functioning, and neuropsychiatric symptoms were significantly correlated with dependence, which in turn had a strong impact on annual cost. Discussion: This study confirms that cost of dementia care increases with dependence and that the impact of other disease indicators is mainly mediated by dependence.

Predicting the progression of Alzheimer's disease dementia: A multidomain health policy model

INTRODUCTION

We develop a multidomain model to predict progression of Alzheimer's disease dementia (AD).

METHODS

Data from the US National Alzheimer's Coordinating Center (n = 3009) are used to examine change in symptom status and to estimate transition probabilities between health states described using cognitive function, functional ability, and behavior. A model is used to predict progression and to assess a hypothetical treatment scenario that slows mild to moderate AD progression.

RESULTS

More than 70% of participants moved state over 12 months. The majority moved in domains other than cognitive function. Over 5 years, of those alive more than half are in severe AD health states. Assessing an intervention scenario, we see fewer years in more severe health states and a potential impact (life years saved) due to mortality improvements.

DISCUSSION

The model developed is exploratory and has limitations but illustrates the importance of using a multidomain approach when assessing impacts of AD and interventions.

Combinations of Service Use Types of People With Early Cognitive Disorders

OBJECTIVES

Understanding which persons most likely use particular combinations of service types is important as this could lead to a better understanding of care pathways. The aim of this study is to identify combinations of service use within a sample of community-dwelling people with mild cognitive impairment (MCI) and dementia and identify factors related to these service use combinations.

METHODS

A latent class analysis performed at baseline on a merged dataset (n = 530) was used to classify care recipients based on following service use types: general practitioner visits, physiotherapist visits, hospital outpatient specialist visits, emergency room visits, hospital inpatient visits with stay over, day care visits, use of domestic homecare, use of personal homecare, and informal care on (instrumental) activities of daily living. Multinomial logistic regression was performed to identify factors associated with service use combinations using clinical characteristics of the care recipient and demographic characteristics of the care recipient and caregiver.

RESULTS

Three service use classes were identified; a formal homecare class (10% of participants), an informal care class (46% of participants), and a low user class (44% of participants). Factors increasing the likelihood of being in the formal homecare class compared with the low service use class included a diagnosis of MCI or dementia, activities of daily living impairment, older age of the care recipient, and care recipient not living together with the caregiver.

CONCLUSIONS

Besides a diagnosis of MCI or dementia, other factors (activities of daily living impairment, age, and living situation) were associated with service use. We recommend using these factors alongside the diagnostic label for care indication.

Economic Impact of Dementia by Disease Severity: Exploring the Relationship between Stage of Dementia and Cost of Care in Taiwan

OBJECTIVE

Given the shortage of cost-of-illness studies in dementia outside of the Western population, the current study estimated the annual cost of dementia in Taiwan and assessed whether different categories of care costs vary by severity using multiple disease-severity measures.

METHODS

This study included 231 dementia patient-caregiver dyads in a dementia clinic at a national university hospital in southern Taiwan. Three disease measures including cognitive, functional, and behavioral disturbances were obtained from patients based on medical history. A societal perspective was used to estimate the total costs of dementia according to three cost sub-categories. The association between dementia severity and cost of care was examined through bivariate and multivariate analyses.

RESULTS

Total costs of care for moderate dementia patient were 1.4 times the costs for mild dementia and doubled from mild to severe dementia among our community-dwelling dementia sample. Multivariate analysis indicated that functional declines had a greater impact on all cost outcomes as compared to behavioral disturbance, which showed no impact on any costs. Informal care costs accounted for the greatest share in total cost of care for both mild (42%) and severe (43%) dementia patients.

CONCLUSIONS

Since the total costs of dementia increased with severity, providing care to delay disease progression, with a focus on maintaining patient physical function, may reduce the overall cost of dementia. The greater contribution of informal care to total costs as opposed to social care also suggests a need for more publicly-funded long-term care services to assist family caregivers of dementia patients in Taiwan.

Hospital care and drug costs from five years before until two years after the diagnosis of Alzheimer’s disease in a Finnish nationwide cohort

Aims: The aim of our study was to investigate costs related to hospital care and drugs utilizing register-based data from five years before until two years after the diagnosis of Alzheimer’s disease (AD) in a nationwide cohort. Methods: Finnish nationwide MEDALZ cohort includes all incident cases with clinically verified diagnosis of AD diagnosed during 2005–2011. The study population included 70,718 persons with AD and age-, gender- and region-of-residence-matched control persons. Data of medical care costs was derived from the prescription register and hospital discharge register. Costs of hospital care were calculated according to Finnish healthcare system unit costs. Costs in six month periods before and after the diagnosis per person-years were analyzed. Results: Persons with AD had higher mean total medical care costs per person-years starting from 0.5–1 years before the diagnosis of AD and remained at a higher level until two years after the diagnosis. The difference in mean total medical care costs was at its highest at six months after the diagnosis (cost difference €5088). After that, persons with AD had costs that reached approximately double those without AD. Hospital care costs constituted the major share (78–84%) of the total medical care costs in both persons with and without AD, whereas drug costs had a minor role. Increase in drug costs was caused by anti-dementia drugs. Conclusions: Costs of hospital stays constituted the most significant portion of medical care costs for persons with AD. Further research should be focused on the causes of hospitalization periods.

Exercise training for managing behavioral and psychological symptoms in people with dementia: A systematic review and meta-analysis

This systematic review and meta-analysis of randomized controlled trials assessed the effects of exercise on behavioral and psychological symptoms of dementia (BPSD, including depression) in people with dementia (PWD). Secondary outcomes for the effects of exercise were mortality and antipsychotic use. Twenty studies were included in this review (n=18 in the meta-analysis). Most studies used a multicomponent exercise training (n=13) as intervention; the control group was often a usual care (n=10) or a socially-active (n=8) group. Exercise did not reduce global levels of BPSD (n=4. Weighted mean difference -3.884; 95% CI -8.969-1.201; I(2)=69.4%). Exercise significantly reduced depression levels in PWD (n=7). Standardized mean difference -0.306; 95% CI -0.571 to -0.041; I(2)=46.8%); similar patterns were obtained in sensitivity analysis performed among studies with: institutionalized people (p=0.038), multicomponent training (p=0.056), social control group (p=0.08), and low risk of attrition bias (p=0.11). Exploratory analysis showed that the principal BPSD (other than depression) positively affected by exercise was aberrant motor behavior. Exercise had no effect on mortality. Data on antipsychotics were scarce. In conclusion, exercise reduces depression levels in PWD. Future studies should examine whether exercise reduces the use (and doses) of antipsychotics and other drugs often used to manage BPSD.

Predictors of Societal Costs in Dementia Patients and Their Informal Caregivers: A Two-Year Prospective Cohort Study

OBJECTIVES

Dementia poses a substantial economic burden on society. Knowing which factors predict high costs in dementia may help to better target interventions and optimize resource allocation. This study aimed to identify predictors of the total societal costs in dementia patients and their informal caregivers.

DESIGN

Prospective cohort study with 2-year follow up.

SETTING AND PARTICIPANTS

192 community-dwelling patients with dementia and their primary informal caregivers in the Netherlands.

MEASUREMENTS

Data on health care resource utilization, informal carer time and caregivers' work absenteeism were collected by cost diaries and interviews. Predictors of total costs were identified for patient-caregiver dyads, and for patients and informal caregivers separately by performing univariate and multivariate generalized linear models.

RESULTS

Societal costs of patient-caregiver dyads averaged €75,084 (SEM: €4,263) in the first year and €99,369 (SEM: €6,441) in the second year. Sixty percent was attributed to costs of informal care. Patient impairments in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), disruptions during daily activities of the caregiver, and receiving case management were significantly associated with higher costs in dyads. The same predictors remained significant for patients' costs separately, and for informal caregivers, a poorer caregiver's quality of life and having more chronic diseases determined higher costs.

CONCLUSIONS

The societal costs of dementia are substantial and mainly due to high costs of informal care. The burden for caregivers caused by a disrupted schedule and patients' ADL and IADL dependencies contributed most to the total costs. Interventions targeting these factors effectively might result in relevant economic benefits for society.

Costs of care for people with dementia just before and after nursing home placement: primary data from eight European countries

BACKGROUND

Dementia is the most common cause of functional decline among elderly people and is associated with high costs of national healthcare in European countries. With increasing functional and cognitive decline, it is likely that many people suffering from dementia will receive institutional care in their lifetime. To delay entry to institutional care, many European countries invest in home and community based care services.

OBJECTIVES

This study aimed to compare costs for people with dementia (PwD) at risk for institutionalization receiving professional home care (HC) with cost for PwD recently admitted to institutional long-term nursing care (ILTC) in eight European countries. Special emphasis was placed on differences in cost patterns across settings and countries, on the main predictors of costs and on a comprehensive assessment of costs from a societal perspective.

METHODS

Interviews using structured questionnaires were conducted with 2,014 people with dementia and their primary informal caregivers living at home or in an ILTC facility. Costs of care were assessed with the resource utilization in dementia instrument. Dementia severity was measured with the standardized mini mental state examination. ADL dependence was assessed using the Katz index, neuropsychiatric symptoms using the neuropsychiatric inventory (NPI) and comorbidities using the Charlson. Descriptive analysis and multivariate regression models were used to estimate mean costs in both settings. A log link generalized linear model assuming gamma distributed costs was applied to identify the most important cost drivers of dementia care.

RESULTS

In all countries costs for PwD in the HC setting were significantly lower in comparison to ILTC costs. On average ILTC costs amounted to 4,491 Euro per month and were 1.8 fold higher than HC costs (2,491 Euro). The relation of costs between settings ranged from 2.4 (Sweden) to 1.4 (UK). Costs in the ILTC setting were dominated by nursing home costs (on average 94%). In the HC setting, informal care giving was the most important cost contributor (on average 52%). In all countries costs in the HC setting increased strongly with disease severity. The most important predictor of cost was ADL independence in all countries, except Spain and France where NPI severity was the most important cost driver. A standard deviation increase in ADL independence translated on average into a cost decrease of about 22%.

CONCLUSION

Transition into ILTC seems to increase total costs of dementia care from a societal perspective. The prevention of long-term care placement might be cost reducing for European health systems. However, this conclusion depends on the country, on the valuation method for informal caregiving and on the degree of impairment.

Epitope Fingerprinting for Recognition of the Polyclonal Serum Autoantibodies of Alzheimer's Disease

Autoantibodies (aAb) associated with Alzheimer's disease (AD) have not been sufficiently characterized and their exact involvement is undefined. The use of information technology and computerized analysis with phage display technology was used, in the present research, to map the epitope of putative self-antigens in AD patients. A 12-mer random peptide library, displayed on M13 phages, was screened using IgG from AD patients with two repetitions. Seventy-one peptides were isolated; however, only 10 were positive using the Elisa assay technique (Elisa Index > 1). The results showed that the epitope regions of the immunoreactive peptides, identified by phage display analysis, were on the exposed surfaces of the proteins. The putative antigens MAST1, Enah, MAO-A, X11/MINT1, HGF, SNX14, ARHGAP 11A, APC, and CENTG3, which have been associated with AD or have functions in neural tissue, may indicate possible therapeutic targets.

Clinical management and associated costs for moderate and severe Alzheimer's disease in urban China: a Delphi panel study

Background

Healthcare resource utilisation for Alzheimer’s disease (AD) in China is not well understood. This Delphi panel study aimed to describe the clinical management pathways for moderate and severe AD patients in urban China and to define the amount and cost of healthcare resources used.

Methods

A panel of 11 experts was recruited from urban China to participate in two rounds of preparatory interviews. In the first round, 9 physicians specialised in dementia gave a qualitative description of the clinical management of AD patients. In the second round, 2 hospital administrators were asked about the cost of AD management and care. Results from the interviews were discussed by the experts in a Delphi panel meeting, where consensus was reached on quantitative aspects of AD management, including the rate of healthcare resource utilisation, the respective unit costs and caregiving time.

Results

Interviewees reported that mild AD is under-recognised in China; most patients are diagnosed with moderate to severe AD. Loss of independence and agitation/aggression are the main drivers for healthcare resource utilisation and contribute to a heavier caregiver burden. It was estimated that 70 % moderate AD patients are independent/non-aggressive at the time of diagnosis, 15 % are independent/aggressive, 10 % are dependent/non-aggressive, and 5 % are dependent/aggressive. Dependent/aggressive AD patients are more likely to be hospitalised (70–90 %) than accepted in a nursing home (0–20 %), while the opposite is true for dependent/non-aggressive patients (5–35 % for hospitalisation vs. 80 % for nursing home). Independent AD patients require 1–3 hours/day of caregiver time, while dependent patients can require up to 12–15 hours/day. Experts agreed that AD complicates the management of age-related comorbidities, found in 70–80 % of all AD patients, increasing the frequency and cost of hospitalisation.

Conclusions

The Delphi panel approach was an efficient method of gathering data about the amount of healthcare resources used and associated costs for moderate and severe AD patients in urban China. The results of this study provide a useful source of information for decision makers to improve future healthcare policies and resource planning, as well as to perform economic evaluations of AD therapies.

Relationship between patient dependence and direct medical-, social-, indirect-, and informal-care costs in Spain

Objective

The objectives of this analysis were to examine how patients’ dependence on others relates to costs of care and explore the incremental effects of patient dependence measured by the Dependence Scale on costs for patients with Alzheimer’s disease (AD) in Spain.

Methods

The Co-Dependence in Alzheimer’s Disease study is an 18 multicenter, cross-sectional, observational study among patients with AD according to the clinical dementia rating score and their caregivers in Spain. This study also gathered data on resource utilization for medical care, social care, caregiver productivity losses, and informal caregiver time reported in the Resource Utilization in Dementia Lite instrument and a complementary questionnaire. The data of 343 patients and their caregivers were collected through the completion of a clinical report form during one visit/assessment at an outpatient center or hospital, where all instruments were administered. The data collected (in addition to clinical measures) also included sociodemographic data concerning the patients and their caregivers. Cost analysis was based on resource use for medical care, social care, caregiver productivity losses, and informal caregiver time reported in the Resource Utilization in Dementia Lite instrument and a complementary questionnaire. Resource unit costs were applied to value direct medical-, social-, and indirect-care costs. A replacement cost method was used to value informal care. Patient dependence on others was measured using the Dependence Scale, and the Cumulative Index Rating Scale was administered to the patient to assess multi-morbidity. Multivariate regression analysis was used to model the effects of dependence and other sociodemographic and clinical variables on cost of care.

Results

The mean (standard deviation) costs per patient over 6 months for direct medical-, social-, indirect-, and informal-care costs were estimated at €1,028.10 (€1,655.00), €843.80 (€2,684.80), €464.20 (€1,639.00), and €33,232.20 (€30,898.90), respectively. Dependence was independently and significantly associated with direct medical-, social-, informal-, and total-care costs.

Conclusion

The costs of care for patients with AD in Spain are substantial, with informal care accounting for the greatest part. Interventions that reduce patient dependence on caregivers may be associated with important reduction in direct medical-, social-, informal-, and total-care costs.

Economic valuation and determinants of informal care to people with Alzheimer's disease

OBJECTIVE

To estimate the monetary value of informal care to people with Alzheimer's disease (AD) in Spain and to identify the main determinants of the time of informal care.

DATA AND METHODS

We used the Survey on Disabilities, Autonomy and Dependency carried out in Spain in 2008 to obtain information on disabled individuals with Alzheimer and their informal caregivers. Assessment of informal care time was performed using three different approaches: the proxy good method, the opportunity cost method and the contingent valuation method. A statistical multivariate analysis--an ordered probit model--was performed to study the determinants of informal care provided.

RESULTS

The average number of required informal hours per year was 4,151. The cost per caregiver ranged from 31,839 to 52,760 euros under the proxy good method; it was estimated at 20,053 euros under the opportunity cost method; and it ranged between 18,680 and 29,057 euros under the contingent valuation method. The degree of dependency and the formal care services were the main variables that explained the variability of the informal time provided. When a person presents a very high level of dependency, the probability of receiving more than 100 h of informal care per week is 25.8% higher than a non-dependent person with AD. Formal in-home care complements informal caregiving, while formal care outside the home replaces it.

CONCLUSIONS

Informal care represents a high social cost in people with AD, regardless of the estimation method considered. A higher level of dependence is associated with more hours of informal care provided.

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.

Monetary costs of agitation in older adults with Alzheimer's disease in the UK: prospective cohort study

OBJECTIVE

While nearly half of all people with Alzheimer's disease (AD) have agitation symptoms every month, little is known about the costs of agitation in AD. We calculated the monetary costs associated with agitation in older adults with AD in the UK from a National Health Service and personal social services perspective.

DESIGN

Prospective cohort study.

SETTING

London and the South East Region of the UK (LASER-AD study).

PARTICIPANTS

224 people with AD recruited between July 2002 and January 2003 and followed up for 54 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was health and social care costs, including accommodation costs and costs of contacts with health and social care services. Agitation was assessed using the Neuropsychiatric Inventory (NPI) agitation score.

RESULTS

After adjustment, health and social care costs varied significantly by agitation, from £29,000 over a 1 year period with no agitation symptoms (NPI agitation score=0) to £57,000 at the most severe levels of agitation (NPI agitation score=12; p=0.01). The mean excess cost associated with agitation per person with AD was £4091 a year, accounting for 12% of the health and social care costs of AD in our data, and equating to £2 billion a year across all people with AD in the UK.

CONCLUSIONS

Agitation in people with AD represents a substantial monetary burden over and above the costs associated with cognitive impairment.

The main cost drivers in dementia: a systematic review

OBJECTIVES

Because of the increasing prevalence of dementia worldwide, combined with limited healthcare expenditures, a better understanding of the main cost drivers of dementia in different care settings is needed.

METHODS

A systematic review of cost-of-illness (COI) studies in dementia was conducted from 2003 to 2012, searching the following databases: PubMed (Medline), Cochrane Library, ScienceDirect (Embase) and National Health Service Economic Evaluations Database. Costs (per patient) by care setting were analyzed for total, direct, indirect and informal costs and related to the following: (1) cost perspective and (2) disease severity.

RESULTS

In total, 27 studies from 14 different healthcare systems were evaluated. In the included studies, total annual costs for dementia of up to $70,911 per patient (mixed setting) were estimated (average estimate of total costs = $30,554). The shares of cost categories in the total costs for dementia indicate significant differences for different care settings. Overall main cost drivers of dementia are informal costs due to home based long term care and nursing home expenditures rather than direct medical costs (inpatient and outpatient services, medication).

CONCLUSIONS

The results of this review highlight the significant economic burden of dementia for patients, families and healthcare systems and thus are important for future health policy planning. The significant variation of cost estimates for different care settings underlines the need to understand and address the financial burden of dementia from both perspectives. For health policy planning in dementia, future COI studies should follow a quality standard protocol with clearly defined cost components and separate estimates by care setting and disease severity.

Indirect cost with dementia: A Brazilian study

Costs with dementia have been the focus of research around the world and indirect costs to the caregiver appear in the literature as responsible for the greatest impact. In Latin American (LA) studies, indirect costs with dementia range from 60% to 75% of family income.

OBJECTIVE

To present preliminary results of the study "Description of the methods and cost analysis with dementia" currently being conducted at the Behavioral and Cognitive Neurology Unit of Hospital de Clínicas of University of São Paulo - HC-FMUSP.

METHODS

A cross-sectional study which, to date, includes interviews of 93 primary caregivers. The research protocol includes a sociodemographic questionnaire, the Functional Assessment Staging (FAST) scale, the Burden Interview (Zarit), an economic classification scale, and the Resource Utilization in Dementia (RUD) scale.

RESULTS

Monthly indirect costs were US$ 1,122.40, US$ 1,508.90 and US$ 1,644.70 stratified into mild, moderate and severe dementia, respectively. The projected annual indirect costs were US$ 13,468.80, US$ 18,106.80 and US$ 19,736.40, representing 69 to 169% of family income.

CONCLUSION

This small sample showed that the impact of indirect costs with dementia in Brazil may be higher than that reported in other Latin American (LA) studies. These initial results may represent an important contribution for further research on costs with dementia in LA.

Cost analysis of early psychosocial intervention in Alzheimer's disease

BACKGROUND/AIM

To investigate the impact of early psychosocial intervention aimed at patients with Alzheimer's disease (AD) and their caregivers on resource use and costs from a societal perspective.

METHODS

Dyads of patients and their primary caregiver were randomised to intervention (n = 163) or control (n = 167) and followed for 3 years. Health care use was extracted from national registers, and the Resource Utilisation in Dementia questionnaire was used to measure informal care and productivity loss. Multiple imputation was used to replace missing data, and non-parametric bootstrapping was used to estimate standard errors.

RESULTS

Overall, there were no statistically significant differences because of large variation in the observations. The average additional cost of psychosocial intervention provision was estimated at EUR 3,401 per patient. This cost masked a reduced use of formal health care and an increased use of informal care.

CONCLUSIONS

Early psychosocial intervention in AD could be cost-saving from a health care perspective, whereas the opposite seems to be true from a broader societal 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.

Direct medical costs in patients with Alzheimer's disease in Taiwan: A population-based study

BACKGROUND

Alzheimer's disease (AD) has the potential to become a major health concern and associated health care costs may become a significant economic burden on society.

OBJECTIVE

The aim of this study was to estimate the direct medical costs attributable to AD in patients aged ≥60 years in Taiwan from 2000 through 2002 and to explore the correlation of these costs with patients' age and sex.

METHODS

This study was based on the National Health Insurance Research Database of Taiwan's National Health Insurance (NHI) program. The NHI program insures >98% of the 23 million inhabitants of Taiwan. Detailed data were extracted from a random sample of 0.2% of inpatient and 5% of outpatient recipients with AD (International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 331.0) who were aged ≥60 years and who received inpatient or outpatient services with claims from January 1, 2000, to December 31, 2002. Duplicate charges for a specific patient and diagnoses of other types of dementia were excluded from this study.

RESULTS

A total of 69,780 patients were found to have a diagnosis of AD. The direct medical costs for outpatients were estimated at US $1.2 million in 2000, US $1.9 million in 2001, and US $2.3 million in 2002; the costs for inpatient care were estimated at US $670,000 in 2000, US $2.4 million in 2001, and US $3.2 million in 2002. The total direct medical costs were estimated at US $1.86 million in 2000, US $4.24 million in 2001, and US $5.48 million in 2002. The increase of total direct medical costs was not significantly correlated with patients' age or sex.

CONCLUSIONS

From 2000 through 2002, the direct medical costs of AD increased annually in Taiwan among patients with AD aged ≥60 years. No significant correlation was found between increased total direct medical costs and sex or age. The cost estimate presented here has implications for future decision making about reallocating medical resources for treating AD in Taiwan.

The use and costs of formal care in newly diagnosed dementia: a three-year prospective follow-up study

OBJECTIVE

To investigate the use of formal care during the first three years after diagnosis of mild dementia and identify cost-predicting factors.

DESIGN

Prospective longitudinal study over three years.

SETTING

An incidence-based bottom-up cost-of-illness study where information about formal health care services was drawn from the municipalities' registers during the first three years after the diagnosis of mild dementia.

PARTICIPANTS

109 patients with mild dementia at baseline, diagnosed according to consensus criteria based on standardized assessments.

MEASUREMENT

The use of formal care as registered by the municipalities' registration systems. Costs were estimated by applying unit costs, including municipal expenses and out-of-pocket contributions. Clinical data were collected at baseline to identify cost-predicting factors.

RESULTS

Costs for formal care were increasing from € 535 per month of survival (MOS) at baseline to € 3,611 per MOS during the third year, with a mean of € 2,420 during the whole observation period. The major cost driver (74%) was institutional care. The costs for people with dementia with Lewy bodies (€ 3,247 per MOS) were significantly higher than for people with Alzheimer disease (€ 1,855 per MOS). The most important cost-predicting factors we identified were the living situation, a diagnosis of non-Alzheimer disease, comorbidity, and daily living functioning. The use of cholinesterase inhibitors was related to lower costs.

CONCLUSION

Formal care costs increased significantly over time with institutional care being the heaviest cost driver. Studies with longer observation periods will be necessary to evaluate the complete socioeconomic impact of the course of dementia.

Early psychosocial intervention in Alzheimer's disease: cost utility evaluation alongside the Danish Alzheimer's Intervention Study (DAISY)

OBJECTIVE

To assess the cost utility of early psychosocial intervention for patients with Alzheimer's disease and their primary caregivers.

DESIGN

Cost utility evaluation alongside a multicentre, randomised controlled trial with 3 years of follow-up.

SETTING

Primary care and memory clinics in five Danish districts.

PARTICIPANTS

330 community-dwelling patients and their primary caregivers.

INTERVENTION

Psychosocial counselling and support lasting 8-12 months after diagnosis and follow-up at 3, 6, 12 and 36 months in the intervention group or follow-up only in the control group.

MAIN OUTCOME MEASURES

The primary outcome measure was the cost of additional quality-adjusted life years (QALYs). Costs were measured from a societal perspective, including the costs of healthcare, social care, informal care and production loss. QALYs were estimated separately for the patient and the caregiver before aggregation for the main analysis.

RESULTS

None of the observed cost and QALY measures were significantly different between the intervention and control groups, although a tendency was noted for psychosocial care leading to cost increases with informal care that was not outweighed by the tendency for cost savings with formal care. The probability of psychosocial intervention being cost-effective did not exceed 36% for any threshold value. The alternative scenario analysis showed that the probability of cost-effectiveness increased over the range of threshold values used if the cost perspective was restricted to formal healthcare.

CONCLUSIONS

A multifaceted, psychosocial intervention programme was found unlikely to be cost-effective from a societal perspective. The recommendation for practice in settings that are similar to the Danish setting is to provide follow-up with referral to available local support programmes when needed, and to restrict large multifaceted intervention programmes to patients and caregivers with special needs until further evidence for cost-effectiveness emerges.

TRIAL REGISTRATION

The study was registered in the Clinical Trial Database as ISRCTN74848736.

An overview of the LASER-AD study: a longitudinal epidemiological study of people with Alzheimer's disease

Research into the epidemiological, clinical characteristics and economic impact of dementia is critical to increase understanding and better inform care and policy, and empower people with Alzheimer's disease (AD) and their families to make preparations and timely decisions about accommodation, care and treatment. The LASER-AD longitudinal study of people with AD and their carers has contributed to our understanding of the progression, characteristics and costs of the disease, and to developing tools that help detect dementia earlier, and screen and identify problems experienced by carers. Our work on quality of life shows that even those with severe dementia can report this meaningfully, although family proxy ratings of quality of life do not necessarily mirror the views of the individual. Despite the impact of the disease process, people with AD experience well-being in adversity and still live fulfilling lives. The study highlights the high prevalence and severity of neuropsychiatric symptoms, carer anxiety, depression and abusive behaviour. It informs future directions for possible interventions, in particular the central role of carer coping strategies in predicting carer mental illness. Current research is building on our findings, which have also been used to inform national and international plans for managing people with dementia and their carers.

A follow-up intervention in severely demented patients after discharge from a special Alzheimer acute care unit: impact on early emergency room re-hospitalization rate

BACKGROUND

Emergency room (ER) re-hospitalizations are prevalent in severe Alzheimer's disease affected older patients.

DESIGN

Quasi-experimental before and after study.

SETTING

Discharge of severely demented patients from a Special Alzheimer Acute Care Unit.

PARTICIPANTS

A total of 390 patients hospitalized in the unit from 2007 through 2009, with at least one of the following characteristics: severe disruptive behavioral and psychological symptoms of dementia (BPSD) (agitation, aggressiveness, and psychotic symptoms), change of living arrangement related to BPSD, exhaustion of the principal caregiver, and discharge of a subject with anosognosia living alone in the community.

INTERVENTION

The intervention consisted of an individualized care plan, targeting the problems observed during the hospital stay, implemented by the means of regular telephone contacts (in the first week after discharge, before the end of the first month, and then at 3 and 6 months) between a geriatric team and the patient's caregiver. Information was gathered on functional decline, BPSD, change of living arrangement and treatment. The calls were followed by a telephone intervention providing advice, support, and information to the caregiver. When required, these calls were followed by a consultation with a physician or psychologist, or by a consultation in the patient's home.

MEASUREMENTS

The primary outcome measure was the ER re-hospitalization rate, defined as occurring within 31 days of discharge.

RESULTS

The early ER re-hospitalization rate was 8.39% in 2007 versus 8.02% in 2008 (p = 0.818) and 7.47% in 2009 (p = 0.563). Vocal disruptive behavior are more prevalent in re-hospitalized patients (9.64% versus 3.97%, p = 0.05) than in non re-hospitalized patients.

CONCLUSION

We found a nonsignificant decrease of early ER re-hospitalization rate at 1 month after discharge. Interventions addressing severe dementia affected patients with BPSD are needed, as this is a major issue in the organization of health care systems.

The cost-effectiveness of a family meetings intervention to prevent depression and anxiety in family caregivers of patients with dementia: a randomized trial

BACKGROUND

Dementia imposes a heavy burden on health and social care systems as well as on family caregivers who provide a substantial portion of the care. Interventions that effectively support caregivers may prevent or delay patient institutionalization and hence be cost-effective. However, evidence about the cost-effectiveness of such interventions is scarce. The aim of this study was to evaluate the cost-effectiveness of a family meetings intervention for family caregivers of dementia patients in comparison with usual care over a period of 12 months.

METHODS

The economic evaluation was conducted from a societal perspective alongside a randomized trial of 192 primary caregivers with community-dwelling dementia patients. Outcome measures included the Quality Adjusted Life-Years (QALY) of caregivers and patients and the incidence of depression and anxiety disorders in caregivers. Missing cost and effect data were imputed using multiple imputations. Bootstrapping was used to estimate uncertainty around the cost-differences and the incremental cost-effectiveness ratio (ICER). The bootstrapped cost-effect pairs were plotted on a cost-effectiveness plane and used to estimate cost-effectiveness curves.

RESULTS

No significant differences in costs and effects between the groups were found. At 12 months, total costs per patient and primary caregiver dyad were substantial: €77,832 for the intervention group and €75,201 for the usual care group (adjusted mean difference per dyad €4,149, 95% CI -13,371 to 21,956, ICER 157,534). The main cost driver was informal care (66% of total costs), followed by patients' day treatment and costs of hospital and long-term care facility admissions (23%). Based on the cost-effectiveness acceptability curves, the maximum probability that the intervention was considered cost-effective in comparison with usual care reached 0.4 for the outcome QALY per patient-caregiver dyad and 0.6 for the caregivers' incidence of depression and/or anxiety disorders regardless of the willingness to pay.

CONCLUSIONS

The annual costs of caring for a person with dementia were substantial with informal care being by far the largest contributor to the total societal costs. Based on this study, family meetings cannot be considered a cost-effective intervention strategy in comparison with usual care.

TRIAL REGISTRATION

ISRCTN register, ISRCTN90163486.

Association between illness progression measures and total cost in Alzheimer's disease

OBJECTIVE

To compare the associations between dependence and clinical measures of cognition, function and behaviour and total care cost using data from a longitudinal study in Alzheimer's disease (AD).

DESIGN

Longitudinal, observational study.

SETTING

Community-dwelling subjects.

PARTICIPANTS

Male and female subjects between 50 and 85 years of age with mild to moderate AD.

INTERVENTION

None.

MEASUREMENTS

Subject dependence was assessed using the Dependence Scale (DS), cognition (ADAS-Cog, MMSE), function (DAD), behaviour (NPI) and resource utilization with the Resource Utilization in Dementia Questionnaire.

RESULTS

The repeated measures models confirmed a significant association between the DS and total care cost indicating an increase in cost with increasing dependence. A 1-unit increase in DS score was associated with a 28.60% increase in total care cost. Model 2 indicated that a one point change in MMSE, DAD and NPI is associated with 5.29%, 2.32% and 1.71% increase in total cost, respectively. Model 3 indicated that a one point change in ADAS-Cog, DAD and NPI is associated with a 1.74%, 2.42%and 1.62% increase in total cost, respectively.

CONCLUSION

Strategies which prevent deterioration in clinical measures or delay dependence should result in total cost savings. The quantitative relationships observed should assist in the economic assessment of interventions which effect cognition, function, behaviour and dependence.

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.

The worldwide economic impact of dementia 2010

OBJECTIVE

To acquire an understanding of the societal costs of dementia and how they affect families, health and social care services, and governments to improve the lives of people with dementia and their caregivers.

METHODS

The basic design of this study was a societal, prevalence-based, gross cost-of-illness study in which costs were aggregated to World Health Organization regions and World Bank income groupings.

RESULTS

The total estimated worldwide costs of dementia were US$604 billion in 2010. About 70% of the costs occurred in western Europe and North America. In such high-income regions, costs of informal care and the direct costs of social care contribute similar proportions of total costs, whereas the direct medical costs were much lower. In low- and middle-income countries, informal care accounts for the majority of total costs; direct social care costs are negligible.

CONCLUSIONS

Worldwide costs of dementia are enormous and distributed inequitably. There is considerable potential for cost increases in coming years as the diagnosis and treatment gap is reduced. There is also likely to be a trend in low- and middle-income countries for social care costs to shift from the informal to the formal sector, with important implications for future aggregated costs and the financing of long-term care. Only by investing now in research and the development of cost-effective approaches to early diagnosis and care can future societal costs be anticipated and managed.

A longitudinal study of risk factors for community-based home help services in Alzheimer's disease: the influence of cholinesterase inhibitor therapy

BACKGROUND

To investigate the long-term effects of cholinesterase inhibitor (ChEI) therapy and the influence of sociodemographic and clinical factors on the use of community-based home help services (HHS) by patients with Alzheimer's disease (AD).

METHODS

This 3-year, prospective, multicenter study included 880 AD patients treated with donepezil, rivastigmine, or galantamine in a routine clinical setting. At baseline and every 6 months, the patients were assessed with several rating scales, including the Mini-Mental State Examination, Instrumental Activities of Daily Living (IADL), and Physical Self-Maintenance Scale. Doses of ChEI and amounts of HHS per week were recorded. Cox regression models were used to predict the time to HHS, and multiple linear regression was used to predict the volume of HHS used.

RESULTS

During the study, 332 patients (38%) used HHS. Factors that both postponed HHS use and predicted lower amounts of HHS were higher doses of ChEIs, better IADL ability, and living with family. Men, younger individuals, and those with a slower IADL decline showed a longer time to HHS, whereas female sex, a lower cognitive status, or more medications at baseline predicted fewer hours of HHS.

CONCLUSIONS

Higher doses of ChEI might reduce the use of HHS, possibly reducing the costs of community-based care. Female spouses provide more informal care than do male spouses, so the likelihood of using HHS is greater among women with AD. The "silent group" of more cognitively impaired and frail elderly AD patients receives less HHS, which might precipitate institutionalization.

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.

Predictive factors for the objective burden of informal care in people with dementia: a systematic review

BACKGROUND

Informal care plays a substantial role in the provision of total care in dementia. Several reviews have been published on the predictive factors of subjective burden; however, such a review lacks information on objective burden, which refers to the amount and/or costs of informal care.

OBJECTIVES

The objectives of this study were to (1) give an overview of the predictive factors that are associated with the objective burden of informal care; (2) discuss whether these factors are similar to the predictive factors of subjective burden; and (3) examine whether they are modifiable.

DESIGN

The literature in a number of international databases was systematically searched. Methodological quality and level of certainty were assessed.

RESULTS

Ten studies were identified as relevant for the purpose of this review, describing a total of 39 predictive factors. Three factors (behavioral problems and impairments regarding daily functioning and cognition) were considered to be predictors of objective burden. Three factors were not related; 12 were potential predictors; and the results of the remaining 22 factors were inconclusive.

CONCLUSIONS

Many factors were found to be (potential) predictors of objective burden, reflecting its complex nature. Objective and subjective burdens are 2 different relevant aspects of informal care. Interventions aimed at countering behavioral problems and impairments regarding daily functioning could reduce objective burden.

Comparison of informal care time and costs in different age-related dementias: a review

OBJECTIVES

Age-related dementia is a progressive degenerative brain syndrome whose prevalence increases with age. Dementias cause a substantial burden on society and on families who provide informal care. This study aims to review the relevant papers to compare informal care time and costs in different dementias.

METHODS

A bibliographic search was performed on an international medical literature database (MEDLINE). All studies which assessed the social economic burden of different dementias were selected. Informal care time and costs were analyzed in three care settings by disease stages.

RESULTS

21 studies met our criteria. Mean informal care time was 55.73 h per week for Alzheimer disease and 15.8 h per week for Parkinson disease (P = 0.0076), and the associated mean annual informal costs were $17,492 versus $3,284, respectively (P = 0.0393).

CONCLUSION

There is a lack of data about informal care time and costs among other dementias than AD or PD. Globally, AD is the most costly in terms of informal care costs than PD, $17,492 versus $3,284, respectively.

Disease progression and costs of care in Alzheimer's disease patients treated with donepezil: a longitudinal naturalistic cohort

BACKGROUND/AIMS

Improved data and methods are needed for modeling disease progression in Alzheimer's disease (AD) for economic evaluation of treatments. The aim is to estimate prediction models for long-term AD progression and subsequently economic outcomes.

METHODS

Three-year follow-up data on 435 patients treated with the cholinesterase inhibitor donepezil in clinical practise were analyzed. Regression models were estimated for long-term prediction of decline in cognitive function (ADAS-cog) and activities in daily living (ADL) ability, risk of institutionalization and costs of care.

RESULTS

The cognitive deterioration was estimated at between 1.6 and 4 ADAS-cog points per every 6 months, increasing with disease severity. Cognitive function was an important predictor of ADL-ability, which itself was the most important predictor of the risk of institutionalization and costs of care. Combining all models in a cross-validation process generated accurate predictions of costs of care at each 6 months follow-up.

CONCLUSION

The proposed methods for representing AD progression and economic outcomes can be used in micro-simulation models for the economic evaluation of new treatments.

Future living arrangements of Singaporeans with age-related dementia

BACKGROUND

With rapid aging, Singapore faces an increasing proportion of the population with age-related dementia. We used system dynamics methodology to estimate the number and proportion of people with mild, moderate, and severe dementia in future years and to examine the impact of changing family composition on their likely living arrangements.

METHODS

A system dynamics model was constructed to estimate resident population, drawing birth and mortality rates from census data. We simulate future mild, moderate, and severe dementia prevalence matched with estimates of total dementia prevalence for the Asian region that includes Singapore. Then, integrating a submodel in which family size trends were projected based on fertility rates with tendencies for dependent elderly adults with dementia to live with family members, we estimate likely living arrangements of the future population of individuals with dementia.

RESULTS

Though lower than other previous estimates, our simulation results indicate an increase in the number and proportion of people in Singapore with severe dementia. This and the concurrent decrease in family size point to an increasing number of individuals with dementia unlikely to live at home.

CONCLUSIONS

The momenta of demographic and illness trends portend a higher number of individuals with dementia less likely to be cared for at home by family members. Traditions of care for frail elderly found in the diverse cultures of Singapore will be increasingly difficult to sustain, and care options that accommodate these demographic shifts are urgently needed.

[Costs of illness in dementia from a societal perspective. An overview]

Dementias are one of the most expensive disease groups among the population aged 65 years and over. This is mainly due to the patients' deficits in activities of daily living which increase with the progression of dementia, leading to an increasing need for care. As a result, the costs of dementia may more than double over the course of the disease. The costs of medical care account for a relatively small share of total costs and are not greatly influenced by disease severity. By contrast, the costs of care make up at least three quarters of total costs in the majority of studies. When patients are cared for in the community, most of the care is often provided informally by relatives. Accordingly, up to 75 or 80% of the costs of illness in this setting, from a societal perspective, may be due to informal care. Additional professional home care accounts for a relatively small share of total costs. The costs of caring for patients who live in the community are directly related to the degree of functional impairment. By contrast, it can be difficult to estimate the costs which are specifically due to dementia in patients that are institutionalised.

Health state values for use in the economic evaluation of treatments for Alzheimer's disease

Alzheimer's disease (AD) is a chronic, progressive, neurodegenerative disease that places a heavy burden on people with the condition, their families and carers, health care systems and society in general. Health-related quality of life (HR-QOL) in patients deteriorates as the cognitive, behavioural and functional symptoms of AD develop. The human and financial cost of AD is forecast to grow rapidly as populations age, and those responsible for planning and financing health care face the challenge of allocating increasingly scarce resources against current and future interventions targeted towards AD. These include calls for early detection and diagnosis, preventative strategies, new medications, residential care, supportive care, and meeting the needs of carers as well as patients. Health care funders in many health systems now require a demonstration of the value of new interventions through a comparison of benefits in terms of improvements in HR-QOL and costs relative to those of competing or existing practices. Changes in HR-QOL provide the basis for the calculation of the quality-adjusted life-year (QALY), a key outcome used in economic evaluations to compare treatments within and between different disease conditions. The objective of this systematic review was to provide a summary of the published health state values (utilities) for AD patients and their carers that are currently available to estimate QALYs for use in health economic evaluations of interventions in AD. The health care literature was searched for articles published in English between 2000 and 2011, using keywords and variants including 'quality-adjusted life years', 'health state indicators', 'health utilities' and the specific names of generic measures of HR-QOL and health state valuation techniques. Databases searched included MEDLINE, EMBASE, NHS EED, PsycINFO and ISI Web of Science. This review identified 12 studies that reported utility values associated with health states in AD. Values for AD health states categorized according to cognitive impairment (where 1 = perfect health and 0 = dead) ranged from mild AD (0.52-0.73) to moderate AD (0.30-0.53) to severe AD (0.12-0.49). Utility values were almost all based on two generic measures of HR-QOL: the EQ-5D and Health Utility Index mark 2/3 (HUI2/3). There were no health state values estimated from condition- or disease-specific measures of HR-QOL. The review also identified 18 published cost-utility analyses (CUAs) of treatments for AD. The CUAs incorporated results from only three of the identified health state valuation studies. Twelve CUAs relied on the same study for health state values. We conclude that the literature on health state values in AD is limited and overly reliant on a single symptom (cognition) to describe disease progression. Other approaches to characterizing disease progression in AD based on multiple outcomes or dependency may be better predictors of costs and utilities in economic evaluations. Patient and proxy ratings were poorly correlated, particularly in patients with more advanced AD. However, proxy ratings displayed the validity and reliability across the entire range of AD severity needed to detect long-term changes relevant to economic evaluation. Further longitudinal research of patient and carer HR-QOL based on multidimensional measures of outcome and utilities is needed.

Pharmacoeconomics of Alzheimer's disease (AD) treatment with cholinesterase inhibitors

Until more effective and especially disease-modifying treatments for Alzheimer's disease (AD) are available, the therapeutic arsenal consists of cholinesterase inhibitors for mild to moderate dementia and memantine for moderate to severe dementia. Health economic data make an important contribution to the planning of healthcare services and the estimation of the cost of drug reimbursement. As such, for cholinesterase inhibitors it is claimed that the direct cost of the drug itself is eclipsed by the cost savings associated with delaying institutionalisation or delaying the time of progression into a more severe disease state. The present manuscript reviews several factors contributing to the costs of AD, gives an overview of available studies claiming the cost-effectiveness of current AD treatments, highlights strengths and weaknesses of the aforementioned studies, and discusses the impact of (early) identification and treatment of AD. It is concluded that there still is a need for long-term follow-up data from prospective cohort studies before the cost-effectiveness of cholinesterase inhibitors for AD can be confirmed.