Direct and indirect cost of managing alzheimer's disease and related dementias in the United States

2022 Alzheimer's disease facts and figures

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

Economic Evaluation of Healthcare Resource Utilization and Costs for Newly Diagnosed Dementia-Related Psychosis

This retrospective cohort study described changes in all-cause healthcare resource utilization (HCRU) and associated costs in dementia patients newly diagnosed with psychosis. Dementia and incident psychosis were identified using diagnostic and pharmacy claims using a Medicare 20% random sample dataset. All-cause HCRU and unweighted and weighted (by person-years of follow-up) HCRU-associated costs were evaluated in the year prior to and the 4 years following diagnosis of psychosis. In 49,509 dementia patients with psychosis, physician visits per patient per year increased from a mean of 26.7 (standard deviation (SD) 20.0) prior to psychosis to 38.4 (SD 41.9) post-psychosis diagnosis. The number of inpatient stay claims increased from 1.0 (SD 1.4) to 1.7 (SD 5.8). Mean unweighted costs for inpatient stays and home healthcare/hospice during 2008–2016 were USD 9989 and USD 3279 prior to a diagnosis of psychosis but increased to USD 25,982 and USD 9901 (weighted: USD 11,779 and USD 6709), respectively, in the year after a psychosis diagnosis. This pattern of a sharp increase in mean costs was also observed in costs adjusted to 2015 USD, and in both unweighted and weighted total and psychosis-related costs. These results indicate the importance of identifying newly diagnosed psychosis in dementia patients as well as the pressing need for management strategies and treatments that can reduce HCRU and costs.

Costs associated with treatment of insomnia in Alzheimer’s disease caregivers: a comparison of mindfulness meditation and cognitive behavioral therapy for insomnia

Background

Among the over 5 million informal caregivers for patients with Alzheimer’s disease (AD) in the United States (US), over 60% experience insomnia. Research on insomnia treatment efficacy in AD caregivers is limited. An ongoing randomized non-inferiority clinical trial, the Caregiver Sleep Research study, is evaluating whether mindfulness meditation is non-inferior to cognitive behavioral therapy for insomnia (CBT-I) in the treatment of insomnia in AD caregivers. The present report examines estimated intervention costs in this ongoing trial.

Methods

Micro-costing was used to itemize and abstract costs of the two interventions: a mindfulness-based intervention known as mindful awareness practices for insomnia (MAP-I); and CBT-I. This approach involves collecting detailed data on resources utilized and the unit costs of those resources, thereby revealing actual resource use and economic costs for each treatment arm. Personnel time, patient time, and supplies were inventoried, and unit costs were applied. Caregiver time costs, including travel, were based on US Labor Bureau home-health aide national mean hourly wages; instructor/staff costs were based on hourly wages. Per-participant and program costs were calculated assuming individual- and group-delivery to reflect real-world implementation. Sensitivity analyses evaluated robustness of estimates.

Results

From the societal perspective, per-participant MAP-I costs were $1884 for individual and $1377 for group delivery; for CBT-I, these costs were $3978 and $1981, respectively. Compared with CBT-I, MAP-I provided cost savings of $2094 (53%) and $604 (30%) per treated caregiver for individual and group delivery, respectively. From the US healthcare system perspective, MAP-I vs. CBT-I participant savings were $1872 (65%) for individual and $382 (44%) for group interventions, respectively. For MAP-I and CBT-I, instructor in-class time was the highest cost component. Results were most sensitive to combined instructor time costs.

Conclusions

Treatment of insomnia with MAP-I, compared to CBT-I, yields substantial cost savings for society and the healthcare system. With this potential for cost savings, results of the ongoing non-inferiority trial have critical implications for insomnia treatment dissemination and its benefits to AD caregivers and other community populations with insomnia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07619-w.

National Institute on Aging seed funding enables Alzheimer's disease startups to reach key value inflection points

INTRODUCTION

The National Institute on Aging (NIA) provides funding to academic researchers and small businesses working in the Alzheimer's Disease (AD) and AD-related dementia (ADRD) fields to help commercialize their products. The NIA uses Small Business Innovation Research (SBIR) awards to bridge the funding gap in the diagnostic, therapeutic, and care interventions areas, enabling startups to reach key value inflection points to achieve scientific milestones.

METHODS

Only publicly available information is reported. The National Institutes of Health Report Portfolio Online Reporting Tool database and the commercial database Global Data, were used to track the progress of companies that received SBIR or Small Business Technology Transfer (STTR) funding from the NIA.

RESULTS

Since 2008, the NIA has awarded $280 million-including $207 million from fiscal year (FY) 2015 to FY 2019-in new small business program awards for AD/ADRD research.

DISCUSSION

NIA seed capital and mentoring programs are critical resources to help small businesses reach key value inflection points and advance their research from concept to commercialization.

Pure Tone Audiometry and Hearing Loss in Alzheimer's Disease: A Meta-Analysis

An association between age-related hearing loss (ARHL) and Alzheimer's Disease (AD) has been widely reported. However, the nature of this relationship remains poorly understood. Quantification of hearing loss as it relates to AD is imperative for the creation of reliable, hearing-related biomarkers for earlier diagnosis and development of ARHL treatments that may slow the progression of AD. Previous studies that have measured the association between peripheral hearing function and AD have yielded mixed results. Most of these studies have been small and underpowered to reveal an association. Therefore, in the current report, we sought to estimate the degree to which AD patients have impaired hearing by performing a meta-analysis to increase statistical power. We reviewed 248 published studies that quantified peripheral hearing function using pure-tone audiometry for subjects with AD. Six studies, with a combined total of 171 subjects with AD compared to 222 age-matched controls, met inclusion criteria. We found a statistically significant increase in hearing threshold as measured by pure tone audiometry for subjects with AD compared to controls. For a three-frequency pure tone average calculated for air conduction thresholds at 500-1,000-2,000 Hz (0.5-2 kHz PTA), an increase of 2.3 decibel hearing level (dB HL) was found in subjects with AD compared to controls (p = 0.001). Likewise, for a four-frequency pure tone average calculated at 500-1,000-2,000-4,000 (0.5-4 kHz PTA), an increase of 4.5 dB HL was measured (p = 0.002), and this increase was significantly greater than that seen for 0.5-2 kHz PTA. There was no difference in the average age of the control and AD subjects. These data confirm the presence of poorer hearing ability in AD subjects, provided a quantitative estimate of the magnitude of hearing loss, and suggest that the magnitude of the effect is greater at higher sound frequencies. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42021288280.

A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship

Little information has been compiled across studies about existing interventions to mitigate issues of medical financial hardship, despite growing interest in health care delivery. The purpose of this qualitative systematic scoping review was to examine content and outcomes of interventions to address medical financial hardship. PRISMA guidelines were applied to present results using PubMed, Scopus, and CINAHL, published between January 1980 and August 2020. Additional studies were identified through reference lists of selected papers. Included studies focused on mitigating medical financial hardship from out-of-pocket (OOP) health care expenses as an intervention strategy with at least 1 evaluation component. Screening 2412 articles identified 339 articles for full-text review, 12 of which met inclusion criteria. Variation was found regarding targets and outcome measurement of intervention. Primary outcomes were in the following categories: financial outcomes (eg, OOP expenses), behavioral outcomes, psychosocial, health care utilization, and health status. No included studies reported significant reduction in OOP expenses, perceptions of financial burden/toxicity, or health status. However, changes were observed for behavioral outcomes (adherence to treatment, patient needs addressed), some psychosocial outcomes (mental health symptoms, perceived support, patient satisfaction), and care utilization such as routine health care. No patterns were observed in the achievement of outcomes across studies based on intensity of intervention. Few rigorous studies exist in this emerging field, and studies have not shown consistent positive effects. Future research should focus on conceptual clarity of the intervention, align outcome measurement and achieve consensus around outcomes, and employ rigorous study designs, measurement, and outcome follow-up.

Predicted Lifetime Health Outcomes for Aducanumab in Patients with Early Alzheimer's Disease

INTRODUCTION

Alzheimer's disease (AD) is a chronic and progressive neurodegenerative disease that places a substantial burden on patients and caregivers. Aducanumab is the first AD therapy approved by the US Food and Drug Administration to reduce a defining pathophysiological feature of the disease, brain amyloid plaques. In the phase 3 clinical trial EMERGE (NCT02484547), aducanumab reduced clinical decline in patients with mild cognitive impairment (MCI) due to AD and mild AD dementia and confirmed amyloid pathology.

METHODS

We used a Markov modeling approach to predict the long-term clinical benefits of aducanumab for patients with early AD based on EMERGE efficacy data. In the model, patients could transition between AD severity levels (MCI due to AD; mild, moderate, and severe AD dementia) and care settings (community vs. institution) or transition to death. The intervention was aducanumab added to standard of care (SOC), and the comparator was SOC alone. Data sources for base-case and scenario analyses included EMERGE, published National Alzheimer's Coordinating Center analyses, and other published literature.

RESULTS

Per patient over a lifetime horizon, aducanumab treatment corresponded to 0.65 incremental patient quality-adjusted life-years (QALYs) and 0.09 fewer caregiver QALYs lost compared with patients treated with SOC. Aducanumab treatment translated to a lower lifetime probability of transitioning to AD dementia, a lower lifetime probability of transitioning to institutionalization (25.2% vs. 29.4%), delays in the median time to transition to AD dementia (7.50 vs. 4.92 years from MCI to moderate AD dementia or worse), and an incremental median time in the community of 1.32 years compared with SOC.

CONCLUSION

The model predicted long-term benefits of aducanumab treatment in patients with MCI due to AD and mild AD dementia and their caregivers. The predicted outcomes provide a foundation for healthcare decision-makers and policymakers to understand the potential clinical and socioeconomic value of aducanumab.

A Systematic Review of the Indirect and Social Costs in Early and Young Onset Dementias

BACKGROUND

The World Health Organization has estimated that worldwide around 50 million people have dementia. The World Alzheimer Report estimated that between 2 and 10% of all cases of dementia begin before the age of 65. Early and young onset dementias (EYOD) provoke more working, social, family, and economic consequences than late onset dementias. All general studies about costs of dementias show that most of them are indirect or social costs. Despite that, very few studies have been performed in EYOD.

OBJECTIVE

To do a systematic review of literature about indirect or social costs in EYOD to know the state of knowledge and to discover gaps that should be filled.

METHODS

A systematic review was performed in the main database: Scopus, PsychInfo, Web of Science (Web of Science Core Collection, Medline and SciELO), and CINAHL. Additionally, we looked for reviews in Cochrane and in the International Prospective Register Of Systematic Reviews (PROSPERO).

RESULTS

Most of the studies are about costs of dementias in general, but they do no differentiate costs for the case of EYOD. Many studies highlight the increased costs for EYOD but very little included evidence of that. 135 papers were selected. Finally, only two were studies providing data. EYOD reduce the odds to get or maintain a job. Most of the care is provided by informal caregivers. The costs in EYOD are 39.26% higher among EYOD than in late onset.

CONCLUSION

There is a lack of studies about social and indirect costs in EYOD. More evidence is needed.

Cost-Benefit Analysis of the COPE Program for Persons Living With Dementia: Toward a Payment Model

BACKGROUND AND OBJECTIVES

There is a critical need for effective interventions to support quality of life for persons living with dementia and their caregivers. Growing evidence supports nonpharmacologic programs that provide care management, disease education, skills training, and support. This cost-benefit analysis examined whether the Care of Persons with Dementia in their Environments (COPE) program achieves cost savings when incorporated into Connecticut's home- and community-based services (HCBS), which are state- and Medicaid-funded.

RESEARCH DESIGN AND METHODS

Findings are based on a pragmatic trial where persons living with dementia and their caregiver dyads were randomly assigned to COPE with HCBS, or HCBS alone. Cost measures included those relevant to HCBS decision makers: intervention delivery, health care utilization, caregiver time, formal care, and social services. Data sources included care management records and caregiver report.

RESULTS

Per-dyad mean cost savings at 12 months were $2 354 for those who received COPE with a mean difference-in-difference of -$6 667 versus HCBS alone (95% CI: -$15 473, $2 734; not statistically significant). COPE costs would consume 5.6%-11.3% of Connecticut's HCBS annual spending limit, and HCBS cost-sharing requirements align with participants' willingness to pay for COPE.

DISCUSSION AND IMPLICATIONS

COPE represents a potentially cost-saving dementia care service that could be financed through existing Connecticut HCBS. HCBS programs represent an important, sustainable payment model for delivering nonpharmacological dementia interventions such as COPE.

Contextual Considerations and Recommendations for Estimating the Value of Alzheimer's Disease Therapies

The pipeline for new treatments for Alzheimer's disease (AD) in the USA contains over 100 different agents, 80% of which can be categorized as disease-modifying therapies. The regulatory approval of the disease-modifying agent aducanumab has brought more attention to the complexity of the diagnosis, evaluation, and treatment of AD and the difficult decisions payers and policy makers will face over the next few years as innovation continues in this space. The value of AD treatment can vary widely according to the perspective of the analysis, sources of data, and methodological approach for the value assessment. This article focuses on AD-specific data gaps and measurement challenges and provides guidance for evidence generation to facilitate better value assessments for future AD treatments.

Comparing the downstream costs and healthcare utilization associated with the use of low-dose computed tomography (LDCT) in lung cancer screening in patients with and without alzheimer's disease and related dementias (ADRD)

OBJECTIVE

This study aims to compare the downstream costs and healthcare utilization associated with using low-dose computed tomography (LDCT) for lung cancer screening in patients with and without Alzheimer's disease and related dementias (ADRD).

METHODS

Based on data from IBM MarketScan Commercial Claims Databases (2014-2018), we have identified four study cohorts: ADRD and non-ADRD patients who went through LDCT screening; ADRD and non-ADRD patients without LDCT screening. Annually healthcare utilization and cost were grouped into outpatient, inpatient, and pharmacy. We used difference-in-differences (DID) models to estimate the downstream healthcare utilization and cost associated with LDCT screening in both ADRD and non-ADRD population. We used a difference-in-difference-in-differences (DDD) model to explore whether LDCT screening was associated with higher downstream cost and healthcare utilization in ADRD population than non-ADRD population.

RESULT

Compared to individuals without LDCT screening, LDCT screening was associated with increased outpatient visits (2.1, 95% CI 0.7, 3.4) and outpatient cost ($2301.0, 95% CI 296.2, 4305.8) in the ADRD population and increased outpatient visits (0.6, 95% CI 0.1, 1.1) in the non-ADRD population within 1 year after screening. Compared with the non-ADRD population, LDCT screening was found to be associated with an additional 1.5 (95% CI 0.2, 2.8) outpatient visits, 0.7 (95% CI 0.1, 1.3) days of inpatient stays, and $4,960.4 (95% CI 532.7, 9388.0) in overall healthcare costs within 1-year after LDCT in the ADRD population (all p < .5).

CONCLUSION

The downstream cost and healthcare utilization associated with LDCT screening were found to be higher in the ADRD population compared to the average population.

The Rhesus Macaque as a Translational Model for Neurodegeneration and Alzheimer's Disease

A major obstacle to progress in understanding the etiology of normative and pathological human brain aging is the availability of suitable animal models for experimentation. The present article will highlight our current knowledge regarding human brain aging and neurodegeneration, specifically in the context of Alzheimer's disease (AD). Additionally, it will examine the use of the rhesus macaque monkey as a pragmatic translational animal model in which to study underlying causal mechanisms. Specifically, the discussion will focus on behavioral and protein-level brain changes that occur within the central nervous system (CNS) of aged monkeys, and compare them to the changes observed in humans during clinically normative aging and in AD.

Bilingual problem-solving training for caregivers of adults with dementia: A randomized, factorial-design protocol for the CaDeS trial

OBJECTIVE

Caregivers of individuals with Alzheimer's disease and related dementias (ADRD) often experience debilitating caregiver burden and emotional distress. To address these negative emotional consequences of caregiving, we will test and refine a strategy training intervention - Problem-Solving Training (PST) - that promotes self-efficacy and reduces caregiver burden and depressive symptoms. Previous research supports efficacy of PST; however, we do not know exactly how many PST sessions are needed or if post-training "boosters" are required to maintain PST benefits. Additionally, we translated and culturally-adapted PST into "Descubriendo Soluciones Juntos" (DSJ), our novel intervention for Spanish-speaking caregivers.

METHOD

In this 2 × 2 factorial design randomized controlled trial, we will test remotely-delivered PST/DSJ sessions for both English- and Spanish-speaking caregivers of persons with ADRD to determine the optimal number of PST/DSJ sessions and ongoing "booster" sessions needed to best help caregivers navigate their current and future needs.

AIMS

1) Compare the efficacy of three vs. six PST/DSJ sessions each with and without booster sessions for decreasing caregiver burden and depression and enhancing caregiver problem-solving; 2) Identify key factors associated with efficacy of PST/DSJ, including age, gender, primary language, relationship to care recipient, and uptake of the PST/DSJ strategy.

RESULTS

These results will establish guidelines needed for an evidence-based, culturally-adapted, and implementable problem-solving intervention to reduce caregiver stress and burden and improve caregiver health and well-being.

CONCLUSION

This work promotes inclusion of diverse and underserved populations and advances therapeutic behavioral interventions that improve the lives of caregivers of individuals with chronic conditions.

Goals of Care Conversations and Subsequent Advance Care Planning Outcomes for People with Dementia

BACKGROUND

Advance care planning has been shown to improve end of life decision-making for people with dementia. However, the impact of goals of care conversations between people with dementia and their caregivers has not been characterized.

OBJECTIVE

In this study, we evaluate the association between goals of care conversations and advance care planning outcomes.

METHODS

Retrospective advance care planning measures were collected via a questionnaire administered to 166 caregivers after the death of the person with dementia for whom they provided care.

RESULTS

At time of death, the majority of decedents with dementia had advance directives, health care agents, and previous goals of care conversations with their caregiver. Goals of care conversations were significantly associated with the perceived usefulness of advance directives, the perceived adherence to advance directives, and decedent dying at their desired place of death, but not with disagreements around end-of-life care.

CONCLUSION

Our findings suggest that goals of care conversations are an important component of advance care planning. These findings support the development of interventions that facilitate such conversations between people with dementia and their caregivers.

Gender Disparities in Anti-dementia Medication Use among Older Adults: Health Equity Considerations and Management of Alzheimer's Disease and Related Dementias

Objective: The prevalence of Alzheimer's disease and related dementias (ADRD) in women is higher than men. However, the knowledge of gender disparity in ADRD treatment is limited. Therefore, this study aimed to determine the gender disparities in the receipt of anti-dementia medications among Medicare beneficiaries with ADRD in the U.S. Methods: We used data from the Medicare Current Beneficiary Survey 2016. Anti-dementia medications included cholinesterase inhibitors (ChEIs; including rivastigmine, donepezil, and galantamine) and N-methyl-D-aspartate (NMDA) receptor antagonists (including memantine). Descriptive analysis and multivariate logistic regression models were implemented to determine the possible gender disparities in the receipt of anti-dementia medications. Subgroup analyses were conducted to identify gender disparities among beneficiaries with Alzheimer's disease (AD) and those with only AD-related dementias. Results: Descriptive analyses showed there were statistically significant differences in age, marital status, and Charlson comorbidities index (CCI) between Medicare beneficiaries who received and who did not receive anti-dementia medications. After controlling for covariates, we found that female Medicare beneficiaries with ADRD were 1.7 times more likely to receive anti-dementia medications compared to their male counterparts (odds ratio [OR]: 1.71; 95% confidence interval [CI]: 1.19-2.45). Specifically, among Medicare beneficiaries with AD, females were 1.2 times more likely to receive anti-dementia medications (Odds Radio: 1.20; 95% confidence interval: 0.58-2.47), and among the Medicare beneficiaries with only AD-related dementias, females were 1.9 times more likely to receive anti-dementia medications (OR: 1.90; 95% CI: 1.23-2.95). Conclusion: Healthcare providers should be aware of gender disparities in receiving anti-dementia medications among patients with ADRD, and the need to plan programs of care to support both women and men. Future approaches to finding barriers of prescribing, receiving and, adhering to anti-dementia medications by gender should include differences in longevity, biology, cognition, social roles, and environment.

Incremental Healthcare Utilization and Cost Burden of Comorbid Insomnia in Alzheimer's Disease Patients

BACKGROUND

Insomnia is associated with worsened clinical outcomes among Alzheimer's disease dementia (AD) patients, increased caregiver burden, and healthcare utilization.

OBJECTIVE

This study aimed to characterize the incremental healthcare burden of insomnia in AD using real-world data.

METHODS

A retrospective observational study was conducted on AD patients selected from the IBM® MarketScan Commercial and Medicare Supplemental Databases. AD patients with claims-based evidence of insomnia were direct matched to a non-insomnia cohort based on demographic factors. Healthcare utilization and associated costs were assessed for a 12-month follow-up period.

RESULTS

A total of 3,500 insomnia AD patients and 9,884 non-insomnia AD patients were analyzed. The insomnia cohort had a higher comorbidity burden at baseline (mean score on Charlson Comorbidity Index 2.5 versus 2.2, p < 0.001) and higher proportions of patients with baseline diagnoses for other conditions including depression: 40%, insomnia cohort versus 25%, non-insomnia (p < 0.001). AD patients with insomnia were more likely to have a claim for inpatient hospitalizations (39.8%versus 32.3%), emergency room services (56.4%versus 48.0%), and skilled-nursing services (42.6%versus 31.9%) (all p < 0.05). Mean total annual healthcare costs during the 12-month follow-up period were significantly higher among AD patients with insomnia as compared to those without. (Mean costs: $37,356 versus $27,990, p < 0.001).

CONCLUSION

AD patients with comorbid insomnia are more likely to use higher-cost healthcare services such as inpatient hospitalization, and skilled nursing, and have higher total healthcare costs. This real-world analysis provides evidence that AD disease management should consider proper treatment of comorbid insomnia due to the incremental burden and cost implications.

Cardiometabolic Modification of Amyloid Beta in Alzheimer's Disease Pathology

In recent years, several studies have suggested that cardiometabolic disorders, such as diabetes, obesity, hypertension, and dyslipidemia, share strong connections with the onset of neurodegenerative disorders such as Parkinson's and Alzheimer's disease (AD). However, establishing a definitive link between medical disorders with coincident pathophysiologies is difficult due to etiological heterogeneity and underlying comorbidities. For this reason, amyloid β (Aβ), a physiological peptide derived from the sequential proteolysis of amyloid precursor protein (APP), serves as a crucial link that bridges the gap between cardiometabolic and neurodegenerative disorders. Aβ normally regulates neuronal synaptic function and repair; however, the intracellular accumulation of Aβ within the brain has been observed to play a critical role in AD pathology. A portion of Aβ is believed to originate from the brain itself and can readily cross the blood-brain barrier, while the rest resides in peripheral tissues that express APP required for Aβ generation such as the liver, pancreas, kidney, spleen, skin, and lungs. Consequently, numerous organs contribute to the body pool of total circulating Aβ, which can accumulate in the brain and facilitate neurodegeneration. Although the accumulation of Aβ corresponds with the onset of neurodegenerative disorders, the direct function of periphery born Aβ in AD pathophysiology is currently unknown. This review will highlight the contributions of individual cardiometabolic diseases including cardiovascular disease (CVD), type 2 diabetes (T2D), obesity, and non-alcoholic fatty liver disease (NAFLD) in elevating concentrations of circulating Aβ within the brain, as well as discuss the comorbid association of Aβ with AD pathology.

Effects of in-person and telephone-based cognitive behavioral therapies on health services use and expenditures among African-American dementia caregivers with depressive symptoms

Objectives: To compare the effects of telephone-based and in-person cognitive behavioral therapy (CBT) on health services use and expenditures among African-American dementia caregivers (CGs) with depressive symptoms.Methods: We analyzed data collected from 109 caregivers in a randomized controlled trial comparing the effects of telephone-based and in-person CBT on health services use and costs. Study participants were assigned randomly to either telephone or in-person CBT. Data were collected one week before and one week after the 12-week intervention. The Health Service Composite (HSC) was used to collect information on health services (physical and mental health, emergency room, hospital) utilization and associated expenditures. Intervention cost data were collected using micro-costing analysis. We used generalized linear models to examine whether the two groups differed in total health care expenditures over the six-month study period.Results: CG characteristics and health services use were similar at pre-intervention. CGs' monthly health expenditures averaged $924 and $844 in the in-person and telephone-based groups, respectively. However, intervention costs were lower for telephone-based than in-person CBT. Adjusting for CG characteristics and pre-intervention health status, there were no statistically significant differences in average monthly expenditures between the two intervention groups across time.Discussion: Findings suggest that while telephone-based CBT offers more participation flexibility, it has a similar cost profile as compared to the in-person CBT. Despite the lack of cost saving, telephone-based CBT may be an important option for providing skills building and support to older African-American family CGs with barriers to access resources for respite care and transportation.

How to analyze work productivity loss due to health problems in randomized controlled trials? A simulation study

Background

An increasing number of randomized controlled trials (RCTs) have measured the impact of interventions on work productivity loss. Productivity loss outcome is inflated at zero and max loss values. Our study was to compare the performance of five commonly used methods in analysis of productivity loss outcomes in RCTs.

Methods

We conducted a simulation study to compare Ordinary Least Squares (OLS), Negative Binominal (NB), two-part models (the non-zero part following truncated NB distribution or gamma distribution) and three-part model (the middle part between zero and max values following Beta distribution). The main number of observations each arm, N_obs, that we considered were 50, 100 and 200. Baseline productivity loss was included as a covariate.

Results

All models performed similarly well when baseline productivity loss was set at the mean value. When baseline productivity loss was set at other values and N_obs = 50 with ≤5 subjects having max loss, two-part models performed best if the proportion of zero loss> 50% in at least one arm and otherwise, OLS performed best. When N_obs = 100 or 200, the three-part model performed best if the two arms had equal scale parameters for their productivity loss outcome distributions between zero and max values.

Conclusions

Our findings suggest that when treatment effect at any given values of one single covariate is of interest, the model selection depends on the sample size, the proportions of zero loss and max loss, and the scale parameter for the productivity loss outcome distribution between zero and max loss in each arm of RCTs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01330-w.

The Potential of Induced Pluripotent Stem Cells to Treat and Model Alzheimer's Disease

An estimated 6.2 million Americans aged 65 or older are currently living with Alzheimer's disease (AD), a neurodegenerative disease that disrupts an individual's ability to function independently through the degeneration of key regions in the brain, including but not limited to the hippocampus, the prefrontal cortex, and the motor cortex. The cause of this degeneration is not known, but research has found two proteins that undergo posttranslational modifications: tau, a protein concentrated in the axons of neurons, and amyloid precursor protein (APP), a protein concentrated near the synapse. Through mechanisms that have yet to be elucidated, the accumulation of these two proteins in their abnormal aggregate forms leads to the neurodegeneration that is characteristic of AD. Until the invention of induced pluripotent stem cells (iPSCs) in 2006, the bulk of research was carried out using transgenic animal models that offered little promise in their ability to translate well from benchtop to bedside, creating a bottleneck in the development of therapeutics. However, with iPSC, patient-specific cell cultures can be utilized to create models based on human cells. These human cells have the potential to avoid issues in translatability that have plagued animal models by providing researchers with a model that closely resembles and mimics the neurons found in humans. By using human iPSC technology, researchers can create more accurate models of AD ex vivo while also focusing on regenerative medicine using iPSC in vivo. The following review focuses on the current uses of iPSC and how they have the potential to regenerate damaged neuronal tissue, in the hopes that these technologies can assist in getting through the bottleneck of AD therapeutic research.

Rural-urban differences in informal caregiving and health-related quality of life

OBJECTIVES

Rural-urban health disparities are pervasive among older adults. Rural US locations have a disproportionately high population of older adults, have reduced access to services, and are therefore more reliant on family and friends for care. However, little is known about rural-urban disparities among the 40+ million informal caregivers nationwide. There is a critical need to understand how rural-urban disparities impact caregiving experiences and health-related quality of life (HRQoL). The objectives of this study were to assess rural-urban differences in informal caregiving status, caregiving intensity (caregiving hours/week and types of care provided), and caregiver HRQoL.

METHODS

Data were abstracted from the 2018 Behavioral Risk Factor Surveillance System. The primary measure of rural-urban status was "metropolitan status." Associations between rural-urban status and caregiving and rural-urban differences in caregiving intensity and HRQoL were examined using generalized linear models, controlling for confounding and accounting for complex sampling.

RESULTS

Rural respondents were more likely to be caregivers than urban respondents (OR = 1.17, 95% CI: 1.02-1.34). After adjustment for confounders, rural caregivers were more likely than urban caregivers to provide 20 or more hours of caregiving per week (OR 1.38, 95% CI: 1.07-1.77), although the findings for health and HRQoL were somewhat mixed.

CONCLUSION

Results indicate that rural older adults offer more care than urban counterparts, which may have implications for caregiver health, well-being, and quality of life. These results can inform policies designed to improve caregiver health, and facilitate the translation and adaptation of existing policies, programs, and interventions to address rural caregivers' needs.

2021 Alzheimer's disease facts and figures

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

Amyloidosis increase is not attenuated by long-term calorie restriction or related to neuron density in the prefrontal cortex of extremely aged rhesus macaques

As human lifespan increases and the population ages, diseases of aging such as Alzheimer's disease (AD) are a major cause for concern. Although calorie restriction (CR) as an intervention has been shown to increase healthspan in many species, few studies have examined the effects of CR on brain aging in primates. Using postmortem tissue from a cohort of extremely aged rhesus monkeys (22-44 years old, average age 31.8 years) from a longitudinal CR study, we measured immunohistochemically labeled amyloid beta plaques in Brodmann areas 32 and 46 of the prefrontal cortex, areas that play key roles in cognitive processing, are sensitive to aging and, in humans, are also susceptible to AD pathogenesis. We also evaluated these areas for cortical neuron loss, which has not been observed in younger cohorts of aged monkeys. We found a significant increase in plaque density with age, but this was unaffected by diet. Moreover, there was no change in neuron density with age or treatment. These data suggest that even in the oldest-old rhesus macaques, amyloid beta plaques do not lead to overt neuron loss. Hence, the rhesus macaque serves as a pragmatic animal model for normative human aging but is not a complete model of the neurodegeneration of AD. This model of aging may instead prove most useful for determining how even the oldest monkeys are protected from AD, and this information may therefore yield valuable information for clinical AD treatments.

Cost of Treatment and Care for People with Alzheimer's Disease: A Meta- Analysis

There is now a general attempt in developed countries to implement strategic plans to fight against Alzheimer's disease, for which treatment represents an increasing economic burden for the ageing society. At present, the costs of treatment and care for Alzheimer's Disease (AD) patients are not consistently tracked and logged, therefore, the economic burden is calculated based on the records kept by individual countries. The aim of this paper is to conduct a meta-analysis of the available data on the total costs of treatment and care for elderly AD patients with respect to the stage of the disease determined by the Mini Mental State Examination (MMSE). The Web of Science and PubMed databases were used for a systematic search. Two independent reviewers screened the identified records and selected relevant articles published in the period from 2007 to 2017. A meta-analysis of costs is performed in three categories related to the stages of Alzheimer's disease (mild, moderate, and severe). The resulting estimation of total costs per patient per year determined by the meta-analysis is 20,461$ total costs. The total costs in relation to the stage of the disease according to the MMSE scale are 14,675 $ for the mild stage, 19,975 $ for the moderate stage, and 29,708 $ for the severe stage. The meta- analysis confirms that the costs rise significantly with the severity of AD. These findings therefore, emphasize the severity of the economic burden carried out by the AD patients, their families, and the healthcare system, and this fact must be taken into account when planning health policy strategies for the years to come.

Tip of the Iceberg: Assessing the Global Socioeconomic Costs of Alzheimer's Disease and Related Dementias and Strategic Implications for Stakeholders

While it is generally understood that Alzheimer’s disease (AD) and related dementias (ADRD) is one of the costliest diseases to society, there is widespread concern that researchers and policymakers are not comprehensively capturing and describing the full scope and magnitude of the socioeconomic burden of ADRD. This review aimed to 1) catalogue the different types of AD-related socioeconomic costs described in the literature; 2) assess the challenges and gaps of existing approaches to measuring these costs; and 3) analyze and discuss the implications for stakeholders including policymakers, healthcare systems, associations, advocacy groups, clinicians, and researchers looking to improve the ability to generate reliable data that can guide evidence-based decision making. A centrally emergent theme from this review is that it is challenging to gauge the true value of policies, programs, or interventions in the ADRD arena given the long-term, progressive nature of the disease, its insidious socioeconomic impact beyond the patient and the formal healthcare system, and the complexities and current deficiencies (in measures and real-world data) in accurately calculating the full costs to society. There is therefore an urgent need for all stakeholders to establish a common understanding of the challenges in evaluating the full cost of ADRD and define approaches that allow us to measure these costs more accurately, with a view to prioritizing evidence-based solutions to mitigate this looming public health crisis.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Health Care Costs of Alzheimer's and Related Dementias Within a Medicare Managed Care Provider

BACKGROUND

Although one third of Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans, there is limited information about the cost of treating Alzheimer disease and related dementias (ADRD) in these settings.

OBJECTIVE

The objective of this study was to estimate direct health care costs attributable to ADRD among older adults within a large MA plan.

RESEARCH DESIGN

A retrospective cohort design was used to estimate direct total, outpatient, inpatient, ambulatory pharmacy, and nursing home costs for 3 years before and after an incident ADRD diagnosis for 927 individuals diagnosed with ADRD relative to a sex-matched and birth year-matched set of 2945 controls.

SUBJECT

Adults 65 years of age and older enrolled in the Kaiser Permanente Washington MA plan and the Adult Changes in Thought (ACT) Study, a prospective longitudinal cohort study of ADRD and brain aging.

MEASURES

Data on monthly health service use obtained from health system electronic medical records for the period 1992-2012.

RESULTS

Total monthly health care costs for individuals with ADRD are statistically greater (P<0.05) than controls beginning in the third month before diagnosis and remain significantly greater through the eighth month following diagnosis. Greater total health costs are driven by significantly (P<0.05) greater nursing home costs among individuals diagnosed with ADRD beginning in the third month prediagnosis. Although total costs were no longer significantly greater at 8 months following diagnosis, nursing home costs remained higher for the people with dementia through the 3 years postdiagnosis we analyzed.

CONCLUSION

Greater total health care costs among individuals with ADRD are primarily driven by nursing home costs.

Cost-effectiveness of a non-pharmacological treatment vs. "care as usual" in day care centers for community-dwelling older people with cognitive impairment: results from the German randomized controlled DeTaMAKS-trial

BACKGROUND

Cognitive impairment in older adults causes a high economic and societal burden. This study assesses the cost-effectiveness of the multicomponent, non-pharmacological MAKS treatment vs. "care as usual" in German day care centers (DCCs) for community-dwelling people with mild cognitive impairment (MCI) or mild to moderate dementia over 6 months.

METHODS

The analysis was conducted from the societal perspective alongside the cluster-randomized controlled, multicenter, prospective DeTaMAKS-trial with waitlist group design. Outcomes were Mini-Mental Status Examination (MMSE) and Erlangen Test of Activities of Daily Living in Persons with Mild Dementia or Mild Cognitive Impairment (ETAM) of 433 individuals in 32 DCCs. Incremental differences in MMSE and ETAM were calculated via a Gaussian-distributed and incremental cost difference via a Gamma-distributed Generalized Linear Model. Cost-effectiveness was assessed via cost-effectiveness planes and cost-effectiveness acceptability curves (CEAC).

RESULTS

At 6 months, MMSE (adjusted mean difference = 0.92; 95% confidence interval (CI): 0.17 to 1.67; p = 0.02) and ETAM (adjusted mean difference = 1.00; CI: 0.14 to 1.85; p = 0.02) were significantly better in the intervention group. The adjusted cost difference was - €938.50 (CI: - 2733.65 to 763.13; p = 0.31). Given the CEAC, MAKS was cost-effective for 78.0% of MMSE and 77.4% for ETAM without a need for additional costs to payers.

CONCLUSIONS

MAKS is a cost-effective treatment to stabilize the ability to perform activities of daily living and cognitive abilities of people with MCI or mild to moderate dementia in German DCCs. Thus, MAKS should be implemented in DCCs.

Therapeutic potential of neurogenesis and melatonin regulation in Alzheimer's disease

Alzheimer's disease (AD) is an age-related neurodegenerative disorder characterized by the hallmark pathologies of amyloid-beta plaques and neurofibrillary tangles. Symptoms of this devastating disease include behavioral changes and deterioration of higher cognitive functions. Impairment of neurogenesis has also been shown to occur in AD, which adversely impacts new neuronal cell growth, differentiation, and survival. This impairment possibly results from the cumulative effects of the various pathologies of AD. Preclinical studies have suggested that the administration of melatonin-the pineal hormone primarily responsible for the regulation of the circadian rhythm-targets the effects of AD pathologies and improves cognitive impairment. It is postulated that by mitigating the effect of these pathologies, melatonin can also rescue neurogenesis impairment. This review aims to explore the effect of AD pathologies on neurogenesis, as well as the mechanisms by which melatonin is able to ameliorate AD pathologies to potentially promote neurogenesis.

Acute Healthcare Utilization of a Multidisciplinary Neurocognitive Dementia Patient Cohort

Background and Purpose

Upon referral from the primary care provider (PCP), dementia is diagnosed either by a neuropsychological evaluation (NPE) or at a multidisciplinary neurocognitive clinic (MNC). Following the NPE, patients continue receiving care from their PCP. In contrast, patients at the MNC are followed by a multidisciplinary care team that provides expertise across specialties in dementia care and education for the patient, family members, and care providers. The purpose of the study was to determine the utilization of acute healthcare services during the 2 years following a diagnosis of dementia in patients from the MNC and NPE.

Methods

A retrospective review was performed of 581 electronic medical records from January 2010 through December 2014 for 2 cohorts of patients diagnosed with dementia 1) by a neuropsychologist or 2) in a MNC. Acute-care hospital admissions, emergency room (ER) visits, and nonroutine PCP visits were identified. Categorical demographics and utilization variables were summarized by frequency. Chi-square analysis was used to analyze demographic characteristics and overall utilization between MNCs and NPE. Utilization in comparison with various demographic characteristics was analyzed using Spearman correlation coefficients and negative binomial regressions.

Results

Patients evaluated in the MNC were older, more severely impaired, and lived alone more often compared with NPE patients, but there was no increase in hospital admissions and ER visits. Patients who underwent NPE were 1.58 times more likely to have a nonroutine PCP office visit than patients evaluated in the MNC (p=0.0093).

Conclusions

Performing follow-up in multidisciplinary clinics provides patients with more education and may help to reduce the utilization of healthcare services.

Cognitive Function, Access to Kidney Transplantation, and Waitlist Mortality Among Kidney Transplant Candidates With or Without Diabetes

RATIONALE & OBJECTIVE

Intact cognition is generally a prerequisite for navigating through and completing evaluation for kidney transplantation. Despite kidney transplantation being contraindicated for those with severe dementia, screening for more mild forms of cognitive impairment before referral is rare. Candidates may have unrecognized cognitive impairment, which may prolong evaluation, elevate mortality risk, and hinder access to kidney transplantation. We estimated the burden of cognitive impairment and its association with access to kidney transplantation and waitlist mortality.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

3,630 participants (January 2009 to June 2018) with cognitive function measured (by the Modified Mini-Mental State Examination [3MS]) at kidney transplantation evaluation at 1 of 2 transplantation centers.

PREDICTORS

Cognitive impairment (3MS score<80).

OUTCOMES

Listing, waitlist mortality, and kidney transplantation.

ANALYTICAL APPROACH

We estimated the adjusted chance of listing (Cox regression), risk for waitlist mortality (competing-risks regression), and kidney transplantation rate (Poisson regression) by cognitive impairment. Given potential differences in cause of cognitive impairment among those with and without diabetes, we tested whether these associations differed by diabetes status using a Wald test.

RESULTS

At evaluation, 6.4% of participants had cognitive impairment, which was independently associated with 25% lower chance of listing (adjusted HR, 0.75; 95% CI, 0.61-0.91); this association did not differ by diabetes status (Pinteraction=0.07). There was a nominal difference by diabetes status for the association between cognitive impairment and kidney transplantation rate (Pinteraction=0.05), while the association between cognitive impairment and waitlist mortality differed by diabetes status kidney transplantation rates (Pinteraction=0.02). Among candidates without diabetes, those with cognitive impairment were at 2.47 (95% CI, 1.31-4.66) times greater risk for waitlist mortality; cognitive impairment was not associated with this outcome among candidates with diabetes.

LIMITATIONS

Single measure of cognitive impairment.

CONCLUSIONS

Cognitive impairment is associated with a lower chance of being placed on the waitlist, and among patients without diabetes, with increased mortality on the waitlist. Future studies should investigate whether implementation of screening for cognitive impairment improves these outcomes.

Development of early diagnosis of Parkinson's disease: Illusion or reality?

The fight against neurodegenerative diseases, Alzheimer disease and Parkinson's disease (PD), is a challenge of the 21st century. The low efficacy of treating patients is due to the late diagnosis and start of therapy, after the degeneration of most specific neurons and depletion of neuroplasticity. It is believed that the development of early diagnosis (ED) and preventive treatment will delay the onset of specific symptoms. This review evaluates methodologies for developing ED of PD. Since PD is a systemic disease, and the degeneration of certain neurons precedes that of nigrostriatal dopaminergic neurons that control motor function, the current methodology is based on searching biomarkers, such as premotor symptoms and changes in body fluids (BF) in patients. However, all attempts to develop ED were unsuccessful. Therefore, it is proposed to enhance the current methodology by (i) selecting among biomarkers found in BF in patients at the clinical stage those that are characteristics of animal models of the preclinical stage, (ii) searching biomarkers in BF in subjects at the prodromal stage, selected by detecting premotor symptoms and failure of the nigrostriatal dopaminergic system. Moreover, a new methodology was proposed for the development of ED of PD using a provocative test, which is successfully used in internal medicine.

The Association of Beta-Blocker Use to Cognitive Impairment among Adults with Hypertension or Cardiovascular Diseases in the United States

BACKGROUND

Some studies have shown that beta-blocker use is associated with better cognitive impairment. However, these studies did not control for pain. The relationship between pain and cognitive impairment has been exhaustively investigated. The association of beta blockers to cognitive impairment in the presence of chronic pain is still unknown.

OBJECTIVE

To examine the independent association of beta-blocker use to cognitive impairment among adults with hypertension or Cardiovascular Diseases (CVDs).

METHODS

We used a cross-sectional study design. We derived data on 8,279 adults from the 2015 Medical Expenditure Panel Survey (MEPS). Study participants were adults (age > 21 years), with hypertension or CVDs and without intracranial injury, Parkinson, Alzheimer's disease and Related Dementia. Cognitive impairment was measured based on 1) confusion or memory loss; 2) problems making decisions, or 3) supervision for participant's safety. Anti-hypertensive medications were categorized into 1) beta-blockers; 2) other anti-hypertensives; and 3) no antihypertensive medication. We used multivariable survey logistic regressions to examine the association between beta-blockers and cognitive impairment after controlling for biological factors, pain, chronic conditions, socioeconomic status, access to healthcare services, behavioral, socio-cultural and external environmental factors.

RESULTS

Overall, 24.2%, 41.9%, and 33.9% reported using beta-blockers, other antihypertensives, and no antihypertensive medications, respectively; 18.1% participants reported cognitive impairment. After controlling for pain, beta-blocker use was not significantly associated with cognitive impairment (AOR= 1.22, 95%CI= 1.00-1.49). In fully adjusted models, the AOR for beta-blockers use was 1.05 (95%CI = 0.84-1.31).

CONCLUSION

In this first large cross-sectional study, we found that the use of beta-blockers was not associated with cognitive impairment. Future prospective studies that include pain management and blood pressure control are needed to confirm the findings.

Direct and indirect costs of home healthcare in Japan: A cross-sectional study

To tackle the rising healthcare expenditure in an ageing society in Japan, home healthcare has been promoted over the past several years. However, there is a dearth of literature on total costs incurring for home healthcare. In this study, we conducted a cross-sectional study among patients, who received home healthcare in the month of May, 2018. Direct healthcare costs and patients' clinical characteristics were collected from medical records and long-term care databases (n = 166). Indirect costs were estimated using a questionnaire survey which obtained information on job absenteeism and care time from the caregiver. A total of 112 patients responded to the survey. The median age was 82 years (interquartile range: 74-88). Total per-person per month home-care costs averaged USD 6,163 with direct costs (USD 2,547) and indirect costs (USD 3,596) accounted for 41.3% and 58.3% of the total costs, respectively. The largest components of direct costs were long-term care costs (48%) and medical costs (47%). Multivariable adjusted model showed that those with heavy healthcare were more likely to incur higher total as well as direct and indirect home healthcare cost (p<.05 for each). Patients aged >75 years (p = .041) were less likely and those who used oxygen at home were more likely to incur direct home healthcare cost (p = .001) than their counterpart. Our study findings show that indirect cost is a major contributor to total home healthcare costs in Japan. Also for patients who need heavy healthcare, both direct and indirect costs are large burden.

Nonimmersive Brain Gaming for Older Adults With Cognitive Impairment: A Scoping Review

BACKGROUND

Technological advances have allowed a variety of computerized cognitive training tools to be engineered in ways that are fun and entertaining yet challenging at a level that can maintain motivation and engagement. This revolution has created an opportunity for gerontological scientists to evaluate brain gaming approaches to improve cognitive and everyday function. The purpose of this scoping review is to provide a critical overview of the existing literature on nonimmersive, electronic brain gaming interventions in older adults with mild cognitive impairment or dementia.

RESEARCH DESIGN AND METHODS

Systematic search was conducted using 7 electronic databases from inception through July 2017. A comprehensive 2-level eligibility process was used to identify studies for inclusion based on PRISMA guidelines.

RESULTS

Seventeen studies met eligibility criteria. Majority of the studies were randomized controlled trials (n = 13) and incorporated an active control (n = 9). Intervention doses ranged from 4 to 24 weeks in duration with an average of 8.4 (±5.1 standard deviation [SD]) weeks. Session durations ranged from 30 to 100 min with an average of 54 (±25 SD) minutes. Nearly half of studies included a follow-up, ranging from 3 months to 5 years (n = 8). For most studies, brain gaming improved at least one cognitive outcome (n = 12); only one study reported improvement in activities of daily living.

DISCUSSION AND IMPLICATIONS

This scoping review conveys the breadth of an emerging research field, which will help guide future research to develop standards and recommendations for brain gaming interventions which are currently lacking.

Differences within Differences: Gender Inequalities in Caregiving Intensity Vary by Race and Ethnicity in Informal Caregivers

Among the 50+ million informal caregivers in the US, substantial gender, racial/ethnic, and socioeconomic disparities in caregiving intensity are well-documented. However, those disparities may be more nuanced: gender disparities in caregiving intensity may vary by race/ethnicity (White, Black, and Hispanic) and socioeconomic status (SES). We used data from the 2011 National Study of Caregiving and applied generalized linear models to estimate associations between three measures of caregiver intensity (ADLs, IADLs, and hours caregiving/month) and the three sociodemographic factors with their interaction terms. Black female caregivers provided significantly higher levels of care than White females and males for both IADL caregiving and hours/month spent caregiving. Black caregivers spent an average of 28.5 more hours/month (95%CI 1.7-45.2) caregiving than White caregivers. These findings highlight the need to understand the complex disparities within population subgroups and how intersections between gender, race/ethnicity, and SES can be used to develop effective policies to reduce disparities and improve caregiver quality-of-life.

2020 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the future challenges of meeting care demands for the growing number of people living with Alzheimer's dementia in the United States with a particular emphasis on primary care. By mid-century, the number of Americans age 65 and older with Alzheimer's dementia may grow to 13.8 million. This represents a steep increase from the estimated 5.8 million Americans age 65 and older who have Alzheimer's dementia today. Official death certificates recorded 122,019 deaths from AD in 2018, the latest year for which data are available, making Alzheimer's the sixth leading cause of death in the United States and the fifth leading cause of death among Americans age 65 and older. Between 2000 and 2018, deaths resulting from stroke, HIV and heart disease decreased, whereas reported deaths from Alzheimer's increased 146.2%. In 2019, more than 16 million family members and other unpaid caregivers provided an estimated 18.6 billion hours of care to people with Alzheimer's or other dementias. This care is valued at nearly $244 billion, but its costs extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2020 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $305 billion. As the population of Americans living with Alzheimer's dementia increases, the burden of caring for that population also increases. These challenges are exacerbated by a shortage of dementia care specialists, which places an increasing burden on primary care physicians (PCPs) to provide care for people living with dementia. Many PCPs feel underprepared and inadequately trained to handle dementia care responsibilities effectively. This report includes recommendations for maximizing quality care in the face of the shortage of specialists and training challenges in primary care.

From Stroke to Dementia: a Comprehensive Review Exposing Tight Interactions Between Stroke and Amyloid-β Formation

Stroke and Alzheimer’s disease (AD) are cerebral pathologies with high socioeconomic impact that can occur together and mutually interact. Vascular factors predisposing to cerebrovascular disease have also been specifically associated with development of AD, and acute stroke is known to increase the risk to develop dementia.

Despite the apparent association, it remains unknown how acute cerebrovascular disease and development of AD are precisely linked and act on each other. It has been suggested that this interaction is strongly related to vascular deposition of amyloid-β (Aβ), i.e., cerebral amyloid angiopathy (CAA). Furthermore, the blood–brain barrier (BBB), perivascular space, and the glymphatic system, the latter proposedly responsible for the drainage of solutes from the brain parenchyma, may represent key pathophysiological pathways linking stroke, Aβ deposition, and dementia.

In this review, we propose a hypothetic connection between CAA, stroke, perivascular space integrity, and dementia. Based on relevant pre-clinical research and a few clinical case reports, we speculate that impaired perivascular space integrity, inflammation, hypoxia, and BBB breakdown after stroke can lead to accelerated deposition of Aβ within brain parenchyma and cerebral vessel walls or exacerbation of CAA. The deposition of Aβ in the parenchyma would then be the initiating event leading to synaptic dysfunction, inducing cognitive decline and dementia. Maintaining the clearance of Aβ after stroke could offer a new therapeutic approach to prevent post-stroke cognitive impairment and development into dementia.

Dementia care-giving and employment: a mixed-studies review on a presumed conflict

Many persons with dementia live at home and are cared for by their relatives. If the relatives are still employed, this can lead to higher burden and losses in their work-life. The interplay between informal care-giving and working is complex. Different studies have explored this issue, but the results have not been yet synthesised. In this mixed-studies review, we elucidate the underlying complexity. Our objective is to identify the factors related to care-giving that influence employment, and to describe their impact on dementia care-givers’ employment. We performed a literature search of primary studies using four databases and one meta-database, and retrieved English- and German-language articles. We used the Mixed Methods Appraisal Tool to assess their methodological quality. Evidence identified was synthesised by a parallel-results convergent synthesis design. We included 55 qualitative, quantitative and mixed-method studies published up to January 2018. The emerging model identified factors linked to the care recipient with dementia, the informal care-giver and the care-giving context. The impacts of these factors on care-givers’ employment are mostly negative (e.g. stopped/reduced work, decreased job performance). Nevertheless, the results provide encouraging insights as working can counterbalance care-giving strain, and managing both roles can enhance care-givers’ wellbeing. Practical efforts should focus on enabling informal care-givers to better manage the balance between care-giving and work responsibilities.

Association of osteoarthritis and pain with Alzheimer's Diseases and Related Dementias among older adults in the United States

BACKGROUND

Emerging evidence suggests that Pain Interference (PI) and certain chronic pain conditions, including Osteoarthritis (OA) may be associated with risk for Alzheimer's disease and Related Dementias (ADRD). However, research exploring the relation of OA and PI to ADRD remains sparse.

OBJECTIVE

To assess the association of OA and PI to ADRD using cross-sectional data from a representative sample of USA adults aged ≥65 years.

DESIGN

Retrospective cross-sectional.

STUDY SAMPLE

Older adults (age ≥ 65 years) drawn from the Medical Expenditure Panel Survey (MEPS, 2009-2015).

METHODS

OA was identified using both medical conditions files and participant responses to arthritis-specific queries. ADRD was ascertained using the medical conditions files. PI was defined as reported frequent PI with normal activities (PIA). OA and PIA were categorized as a composite variable: 1) OA with PIA; 2) OA without PIA; 3) No OA with PIA; and 4) No OA and no PIA (reference group). Adjusted associations of OA and PIA to ADRD were assessed using logistic regression and adjusted for biological, demographic, socio-economic, lifestyle, and health conditions.

RESULTS

Overall, 27.1% had OA, of whom 47.6 % reported PIA vs 31.1% of those without OA; 2.8% had diagnosed ADRD. Adults with PIA either with or without OA had significantly higher odds of ADRD relative to those without OA or PIA (Adjusted odd ratios (AOR's) = 1.37, 95%CI - 1.01, 1.86 (p = 0.04) and 1.44, 95%CI - 1.13, 1.82 (p = 0.003), respectively).

CONCLUSION

PIA in both the presence and absence of OA remained significantly and positively associated with ADRD after adjustment for multiple confounders.

Plasmon-Activated Water Reduces Amyloid Burden and Improves Memory in Animals with Alzheimer's Disease

With the great extension of the human lifespan in recent times, many aging diseases have inevitably followed. Dementia is one of the most-commom neurodegenerative aging diseases, in which inflammation-related Alzheimer’s disease (AD) is the most prevalent cause of dementia. Amyloid accumulation in the brain, which occurs before any clinical presentations, might be the first and key step in the development of AD. However, many clinical trials have attempted to remove amyloid from brains of AD patients, but none has so far been successful. Negatively charged plasmon-activated water (PAW) is created by resonantly illuminated gold (Au) nanoparticles (NPs), which reduce the hydrogen-bonded (HB) structure of water. PAW was found to possess anti-oxidative and anti-inflammatory effects. Herein, we report on an innovative strategy to retard the progression of AD by the daily consumption of PAW instead of normal deionized (DI) water. APPswe/PS1dE9 transgenic mice were treated with PAW or DI water from the age of 5 months for the next 9 months. Encouragingly, compared to DI water-treated mice, mice treated with PAW presented better memory performance on a test of novel object recognition and had a significantly lower amyloid burden according to 18F-florbetapir amyloid-PET and phosphorylated (p)-tau burden according to Western blotting and immunohistochemistry measurements. There were no obvious side effects in PAW-treated mice. Collectively, our findings support that PAW was able to reduce the amyloid and p-tau burden and improve memory in an AD mouse model. However, the protein levels of molecules involved in amyloid metabolism and oligomeric amyloid did not change. We propose that the effects of PAW of reducing the amyloid burden and improving memory function cannot be attributed to synthesis/degradation of amyloid-βprotein but probably in preventing aggregation of amyloid-β proteins or other mechanisms, including anti-inflammation. Further applications of PAW in clinical trials to prevent the progression of AD are being designed.

Accelerated Ovarian Failure as a Unique Model to Study Peri-Menopause Influence on Alzheimer's Disease

Despite decades of extensive research efforts, efficacious therapies for Alzheimer's disease (AD) are lacking. The multi-factorial nature of AD neuropathology and symptomatology has taught us that a single therapeutic approach will most likely not fit all. Women constitute ~70% of the affected AD population, and pathology and rate of symptoms progression are 2-3 times higher in women than men. Epidemiological data suggest that menopausal estrogen loss may be causative of the more severe symptoms observed in AD women, however, results from clinical trials employing estrogen replacement therapy are inconsistent. AD pathological hallmarks-amyloid β (Aβ), neurofibrillary tangles (NFTs), and chronic gliosis-are laid down during a 20-year prodromal period before clinical symptoms appear, which coincides with the menopause transition (peri-menopause) in women (~45-54-years-old). Peri-menopause is marked by widely fluctuating estrogen levels resulting in periods of irregular hormone-receptor interactions. Recent studies showed that peri-menopausal women have increased indicators of AD phenotype (brain Aβ deposition and hypometabolism), and peri-menopausal women who used hormone replacement therapy (HRT) had a reduced AD risk. This suggests that neuroendocrine changes during peri-menopause may be a trigger that increases risk of AD in women. Studies on sex differences have been performed in several AD rodent models over the years. However, it has been challenging to study the menopause influence on AD due to lack of optimal models that mimic the human process. Recently, the rodent model of accelerated ovarian failure (AOF) was developed, which uniquely recapitulates human menopause, including a transitional peri-AOF period with irregular estrogen fluctuations and a post-AOF stage with low estrogen levels. This model has proven useful in hypertension and cognition studies with wild type animals. This review article will highlight the molecular mechanisms by which peri-menopause may influence the female brain vulnerability to AD and AD risk factors, such as hypertension and apolipoprotein E (APOE) genotype. Studies on these biological mechanisms together with the use of the AOF model have the potential to shed light on key molecular pathways underlying AD pathogenesis for the development of precision medicine approaches that take sex and hormonal status into account.

Using Computer Tablets to Improve Moods for Older Adults With Dementia and Interactions With Their Caregivers: Pilot Intervention Study

BACKGROUND

Persons living with dementia represent a significant and growing segment of the older adult (aged 65 years and older) population. They are often challenged expressively and may experience difficulties with sharing their feelings or moods. Availability of, and easy access to, tablets facilitates the use of information and communication technologies (ICTs) as a delivery mechanism for nonpharmacological interventions, especially for persons living with dementia. Evidence of the impact of ICTs in different community settings on mood with older adults and the impact of engagement on their caregivers is needed to promote broader adoption and sustainment of these technologies in the United States.

OBJECTIVE

This study aimed to determine the extent of the effects of tablets on positive mood change and examine the effects of study variables on care recipients' mood changes and caregivers' daily interactions.

METHODS

The tablet intervention was developed and evaluated in five programs. The primary outcome was caregivers' assessment of care recipients' mood (n=1089) before and after a tablet engagement session using an eight-point mood visual analog scale. Session influence on caregivers' daily activities was captured for a subsample of participants (n=542). Frequency distributions were computed for each study variables. Chi-square tests of association were calculated to determine the association of the variables on mood changes for all care recipients, as well as those being treated in skilled nursing facilities and in-home, and then for those that affected caregivers' daily activities.

RESULTS

The study sample comprised 1089 care recipient and caregiver engagement sessions. Cumulatively, 50.78% (553/1089) of care recipients showed a transition from negative to positive moods, whereas another 41.78% (455/1089) maintained an already-positive mood after the caregiver engagement session. Chi-square analyses demonstrated that positive mood changes resulted from using music (χ210=72.9; P<.001), using YouTube as the sole app (χ212=64.5; P<.001), using multiple engagement strategies (χ22=42.8; P<.001), and when cared for in a skilled nursing facility (χ24=236.8; P<.001) across the entire care recipient sample. In addition, although many features of the engagement session positively influenced the caregivers' day, the largest effect was observed when care recipients' mood was considered to have improved following the session (χ24=234.7; P<.001).

CONCLUSIONS

The study is one of the first in the United States to explore the impact of ICTs, in particular managed tablets and Web-based video services that can be used on a tablet through an app, on improving mood in persons living with dementia, and enhancing caregivers' perceptions about their care recipient interactions. Importantly, these pilot data substantiate ICTs as part of a personalized engagement approach, as beneficial alternatives to pharmaceutical interventions for mood enhancement. However, a more comprehensive study that explores the ICT's impact on additional clinical outcomes is needed to confirm these preliminary findings.

Therapeutic strategies for glucose transporter 1 deficiency syndrome

Proper development and function of the mammalian brain is critically dependent on a steady supply of its chief energy source, glucose. Such supply is mediated by the glucose transporter 1 (Glut1) protein. Paucity of the protein stemming from mutations in the associated SLC2A1 gene deprives the brain of glucose and triggers the infantile‐onset neurodevelopmental disorder, Glut1 deficiency syndrome (Glut1 DS). Considering the monogenic nature of Glut1 DS, the disease is relatively straightforward to model and thus study. Accordingly, Glut1 DS serves as a convenient paradigm to investigate the more general cellular and molecular consequences of brain energy failure. Here, we review how Glut1 DS models have informed the biology of a prototypical brain energy failure syndrome, how these models are facilitating the development of promising new treatments for the human disease, and how important insights might emerge from the study of Glut1 DS to illuminate the myriad conditions involving the Glut1 protein.

Cost of dementia in Medicare managed care: a systematic literature review

OBJECTIVES

We conducted a systematic review of studies reporting the direct healthcare costs of treating older adults with diagnosed Alzheimer disease and related dementias (ADRD) within private Medicare managed care plans.

STUDY DESIGN

A systematic review of all studies published in English reporting original empirical analyses of direct costs for older adults with ADRD in Medicare managed care.

METHODS

All papers indexed in PubMed or Web of Science reporting ADRD costs within Medicare managed care plans from 1983 through 2018 were identified and reviewed.

RESULTS

Despite the growth in Medicare managed care enrollment, only 9 papers report the costs of care for individuals with ADRD within these plans, and only 1 study reports data less than 10 years old. This limited literature reports wide ranges for ADRD-attributable costs, with estimates varying from $3738 to $8726 in annual prevalent costs and $8938 to $38,794 in 1-year immediate postdiagnosis incident costs. Reviewed studies also used varied study populations, case and cost ascertainment methods, and analytic methods, making cross-study comparisons difficult.

CONCLUSIONS

The expected continued growth in Medicare managed care enrollment, coupled with the large and growing impact of ADRD on America's healthcare delivery and finance systems, requires more research on the cost of ADRD within managed care. This research should use more consistent approaches to identify ADRD prevalence and provide more detail regarding which components of care are included in analyses and how the costs of care are captured and measured.

A scalable solution for isolating human multipotent clinical-grade neural stem cells from ES precursors

Background

A well-characterized method has not yet been established to reproducibly, efficiently, and safely isolate large numbers of clinical-grade multipotent human neural stem cells (hNSCs) from embryonic stem cells (hESCs). Consequently, the transplantation of neurogenic/gliogenic precursors into the CNS for the purpose of cell replacement or neuroprotection in humans with injury or disease has not achieved widespread testing and implementation.

Methods

Here, we establish an approach for the in vitro isolation of a highly expandable population of hNSCs using the manual selection of neural precursors based on their colony morphology (CoMo-NSC). The purity and NSC properties of established and extensively expanded CoMo-NSC were validated by expression of NSC markers (flow cytometry, mRNA sequencing), lack of pluripotent markers and by their tumorigenic/differentiation profile after in vivo spinal grafting in three different animal models, including (i) immunodeficient rats, (ii) immunosuppressed ALS rats (SOD1_G93A), or (iii) spinally injured immunosuppressed minipigs.

Results

In vitro analysis of established CoMo-NSCs showed a consistent expression of NSC markers (Sox1, Sox2, Nestin, CD24) with lack of pluripotent markers (Nanog) and stable karyotype for more than 15 passages. Gene profiling and histology revealed that spinally grafted CoMo-NSCs differentiate into neurons, astrocytes, and oligodendrocytes over a 2–6-month period in vivo without forming neoplastic derivatives or abnormal structures. Moreover, transplanted CoMo-NSCs formed neurons with synaptic contacts and glia in a variety of host environments including immunodeficient rats, immunosuppressed ALS rats (SOD1G93A), or spinally injured minipigs, indicating these cells have favorable safety and differentiation characteristics.

Conclusions

These data demonstrate that manually selected CoMo-NSCs represent a safe and expandable NSC population which can effectively be used in prospective human clinical cell replacement trials for the treatment of a variety of neurodegenerative disorders, including ALS, stroke, spinal traumatic, or spinal ischemic injury.

Electronic supplementary material

The online version of this article (10.1186/s13287-019-1163-7) contains supplementary material, which is available to authorized users.