Cost of Alzheimer's disease and related dementia in managed-medicare

Prevalence, resource utilization and costs of vascular dementia compared to Alzheimer's dementia in a population setting

OBJECTIVES

To determine the prevalence of dementia and to measure the monetary impact and health resources utilization of vascular dementia (VD) compared to Alzheimer's dementia (AD) in persons aged over 64 years in a population setting.

METHODS

Retrospective, cross-sectional study. In the initial phase, information was obtained on specific clinical characteristics from the subjects with an active diagnosis of dementia. The second phase consisted of a clinical evaluation and validation of the cases. Mini-Mental State Examination was used to assess cognitive impairment. Dementia and its subtypes were determined using established diagnostic criteria. Information was obtained on the use of health care resources (direct costs) and the number of hours devoted by the primary caregiver (indirect costs) for patients with a documented diagnosis of AD or VD within the last 6 months prior to the interview. A multiple logistic regression analysis was performed to correct the model.

RESULTS

A total of 6,004 subjects were analyzed, 258 with diagnosis of dementia (overall prevalence: 4.3%). An evaluation was made of 224 patients, and gross prevalence of AD and VD was 2.4 and 1.0%, respectively. Cost per patient per semester was EUR 8,086 for AD and EUR 11,039 for VD (p = 0.016). 85.5% of the cost was attributable to primary caregiver time in AD and 84.4% in VD.

CONCLUSIONS

The prevalence of AD and VD increases with age. No sociodemographic differences were seen between AD and VD. Costs associated with health care resource and primary caregiver utilization were high, being higher in VD than in AD.

Delirium superimposed on dementia in a community-dwelling managed care population: a 3-year retrospective study of occurrence, costs, and utilization

BACKGROUND

Dementia is a growing public health problem and a well-described risk factor for delirium. Yet little is known about delirium superimposed on dementia in community-dwelling populations. The purpose of this study was to examine the 3-year occurrence, healthcare utilization, and costs associated with delirium superimposed on dementia in community-dwelling persons.

METHODS

We used a 3-year cross-sectional, retrospective design with an administrative database from a large managed care organization. Four individually matched samples of 699 individuals each were selected for comparison purposes: delirium superimposed on dementia (DSD), dementia alone, delirium alone, and a control group with neither delirium nor dementia. The occurrence rate of DSD was calculated by measuring those individuals with a dementia diagnosis that were also coded with an International Classification of Diseases, Ninth Edition Clinical Modification (ICD-9 CM) code for delirium or delirium with dementia.

RESULTS

Of the total sample of 76,688 persons aged 65 years or older in the managed care organization, 7347 (10%) were coded as having dementia, and an additional 763 (1%) as having delirium alone. Among the 7347 with dementia, 976 (13%) had DSD, representing 1.3% of the total sample. After log transformation of total costs and adjustment for multiple covariates, the adjusted mean total health care costs remained significantly higher for the DSD group than for all other groups.

CONCLUSIONS

This study is the first to report the occurrence rate of DSD in a community-dwelling population, and to demonstrate the substantial health care costs and utilization associated with DSD.

Validation of a Brief Screen for Cognitive Impairment (BSCI) Administered by Telephone for Use in the Medicare Population

The aim of this research was to examine the validity of a brief screen for cognitive impairment (BSCI) consisting of three questions administered by telephone (delayed recall, frequency of help with planning trips for errands, and frequency of help remembering to take medications). The study design was an age and gender matched case-control study. Seventy managed care members, 35 with dementia (cases) and 35 without dementia (controls), were assessed using BSCI embedded within a longer health assessment questionnaire commonly used in Medicare-managed care. A number of measures were used to examine validity of BSCI, including comparisons of the differences between cases and controls in BSCI scores, comparisons of the correlations between patient scores on BSCI and the Mini Mental Status Exam (MMSE, a common screening test for dementia) and the Alzheimer's Disease Assessment Scale (ADAS, a common dementia assessment test), and comparisons of the areas under the receiver operating characteristic (ROC) curves for the three instruments. BSCI scores for cases and controls were significantly different, as were their scores for the MMSE and ADAS. Scores on BSCI were significantly correlated with scores for the MMSE and ADAS using both the Kendall's tau-b and Spearman rank-order correlation; correlations ranged from 0.654 between BSCI and ADAS to -0.83 for the correlation between BSCI and the MMSE (p < 0.001 for both). The areas under the ROC curves ranged from 0.94 to 0.96 for the three tests, meaning that they were equally accurate in discriminating between demented and nondemented patients. BSCI, a brief telephone screen for cognitive impairment due to dementia, discriminates between demented patients and normal controls as well as two standard tests of dementia, and may be considered a valid screen for dementia. Compared to existing screening tests, it has the additional advantages of extreme brevity, and ease of administration and scoring by lay interviewers via telephone. The use of brief screening instruments for dementia, such as the one validated here, will be increasingly important for the effective management of dementia and other chronic diseases where dementia is a coexisting condition.

Impact of donepezil use in routine clinical practice on health care costs in patients with Alzheimer's disease and related dementias enrolled in a large medicare managed care plan: A case-control study

BACKGROUND

Clinical studies have shown efficacy of cholinesterase inhibitors (eg, donepezil) in mild to moderate Alzheimer's disease (AD). However, there are limited studies examining the impact on health care costs of cholinesterase inhibitors prescribed in routine clinical practice.

OBJECTIVE

The purpose of this study was to estimate the impact of donepezil use on health care costs and utilization in patients with mild to moderate AD and related dementias.

METHODS

This case-control study was conducted using data from the Health Insurance Plan of Greater New York (New York, New York). Data from patients with predominantly mild to moderate AD and related dementias who were enrolled in this Medicare managed care plan from January 1, 1999, to December 31, 2002, were included. The health care costs and utilization of patients who had received donepezil prescribed in routine clinical practice were compared with those of patients who had never received donepezil or other cholinesterase inhibitors (control group). The 2 study groups were matched for age, sex, number of comorbid conditions, and presence of complications of late-stage dementia. Regression analysis was used to estimate the impact of donepezil use on health care costs and utilization during a 12-month follow-up period, controlling for characteristics associated with the outcomes. The analyses did not use a direct measure of disease severity but instead used proxy measures of severity based on medical conditions associated with late-stage dementia.

RESULTS

Data from 687 patients were included in the study. The donepezil group comprised 229 patients (140 women, 89 men; mean age, 79.6 years); the control group, 458 patients (280 women, 178 men; mean age, 80.0 years). The mean costs of medical services per year in the donepezil group were US $2500 (95% CI, $300-$4671) less than those in the control group (P = 0.024). Lower medical costs in the donepezil group ($3325; 95% CI, $1163-$5486; P < 0.003 vs controls) were largely attributable to the lower costs of services performed in the hospital ($2594; 95% CI, $846-$4341; P < 0.004 vs controls) and postacute skilled nursing facility (SNF) ($1012; 95% CI, $444-$1579; P < 0.001 vs controls), which were partially offset by $1241 in higher prescription, physician's office, and outpatient hospital costs. Patients receiving donepezil had shorter mean lengths of stay in the hospital (3.00 vs 5.43 days; 95% CI, 0.66-4.19; P < 0.008) and postacute SNF (0.42 vs 3.40 days; 95% CI, 1.28-4.69; P < 0.001) but a higher mean number of physician's office visits (10.91 vs 7.91 visits; 95% CI, 1.63-4.36; P < 0.001) compared with controls.

CONCLUSIONS

In this case-control study in patients with predominantly mild to moderate AD and related dementias, donepezil therapy prescribed in routine clinical practice was associated with reduced health care costs to the Medicare managed care plan studied. The findings support previous pharmacoeconomic studies with larger sample sizes obtained over a longer period of time, and with improved case-matching criteria.

Usefulness of a single item in a mail survey to identify persons with possible dementia: a new strategy for finding high-risk elders

The objective of this study was to examine the characteristics of elderly persons who responded positively to a question about "severe memory problems" on a mailed health questionnaire yet were missed by the existing health risk algorithm to identify vulnerable elderly persons. A total of 324,471 respondents aged 65 and older completed a primary care health status questionnaire that gathered clinical information to quickly identify members with functional impairment, multiple chronic diseases, and higher medical care needs. The respondents were part of a large, integrated, not-for-profit managed care organization that implemented a model of care for elders using a uniform risk identification method across eight regions. Respondents with severe memory problems were compared to general respondents by morbidity, geriatric syndromes, functional impairments, service utilization, sensory impairments, sociodemographic characteristics, and activities of daily living. Of the respondents, 13,902 persons (4.3%) reported severe memory problems; the existing health risk algorithm missed 47.1% of these. When severe memory problems were included in the risk algorithm, identification increased from 11% to 13%, and risk prevalence by age groups ranged from 4.4% to 40.5%; one third had severe memory problems, a finding that was fairly consistent within age groups (28.4% to 36.5%). A question about severe memory problems should be incorporated into population risk-identification techniques. While false-negative rates are unknown, the false-positive rate of a self-report mail survey appears to be minimal. Persons reporting severe memory problems clearly have multiple comorbidities, higher prevalence of geriatric syndromes, and greater functional and sensory impairments.

Underrecognition of cognitive impairment in assisted living facilities

OBJECTIVES

To determine the prevalence of cognitive impairment (CI), dementia diagnosis and treatment, assistance with medications, and surrogate decision-makers for residents of assisted living facilities (ALFs).

DESIGN

Cross-sectional study.

SETTING

Seven ALFs in Omaha, Nebraska, and the surrounding area. None of the ALFs in this study were designated "Alzheimer's" or "dementia" facilities.

PARTICIPANTS

Four hundred seven of 455 ALF residents were solicited, and 230 consented. The average age +/- standard deviation of participants was 83.3+/-8.3.

MEASUREMENTS

ALF residents were examined using the Mini-Mental State Examination (MMSE), and their medical charts were reviewed.

RESULTS

Fifty-eight percent of ALF residents had CI according to the MMSE. Of those with CI, 63% had no diagnosis of dementia, 75% were not treated for dementia, 41% with a documented diagnosis of dementia were not treated for dementia, 22% self-administered an average of 5.4+/-3.4 medications daily, and 11% had surrogate decision makers.

CONCLUSION

More than half of ALF residents in this study had CI and a significant percentage was undiagnosed. Even when diagnosed as dementia, CI is significantly undertreated in this setting. These deficits must be addressed to promote quality of care and the need for specialized attention.

Economics of dementia and pharmacoeconomics of dementia therapy

BACKGROUND

The economic impact of dementia is not well appreciated, even though Alzheimer's disease and related dementias were the third most expensive health condition in the United States in 2000. In 1997, the cost of managing patients with Alzheimer's disease and other dementias was estimated at US dollar 100 billion. Direct medical costs are compounded by indirect costs of care, including unpaid care and loss of earnings.

OBJECTIVE

The aim of this review was to examine studies of the economic impact of approved treatments for dementia therapy.

METHODS

Searches of the MEDLINE database were conducted to identify prospective, randomized trials and retrospective or modeling studies of the economic impact of dementia medications, as well as analyses of managed care data (years 1996-2004; English language; search terms: dementia or Alzheimer's cross-referenced with economic or costs).

RESULTS

Only 3 studies directly examined the economic effects of dementia therapy. Two of these demonstrated economic benefits of treatment, whereas the third study concluded that there were no benefits; however, the conclusions of the latter study may have been weakened by such factors as the high rate of attrition and biased selection of study participants. Modeling studies and analyses of managed care data also indicate economic benefits from approved treatments.

CONCLUSIONS

Therapies that are efficacious early in the disease can postpone the progression of dementia to more severe stages and may offer economic benefit to patients' families, caregivers, and society.

Impact économique de la démence

An epidemiology closely linked with the increase in life span. In most countries, the prevalence of dementia varies between 6 and 8% for individuals aged 65 years or more. It then dramatically increases with each subsequent decade, reaching around 30% of the population aged over 85. The costs associated with dementia are correlated with the increase in age and are of increasing concern for politicians, healthcare professionals and family members of demented patients. Current estimations are approximate, but dementia appears to be the most costly disease for society after the age of 65 years in France, the Netherlands, Sweden, or the United States. Detailed cost analyses have distinguished the direct medical,direct non-medical and intangible costs. The most important contribution in costs for society is the long-term care by health care professionals (institutionalization corresponding to 2/3 of the total costs for society!), but the care provided by the helpers and the families is even greater, even though difficult to quantify. The current question is to know whether present and future medical treatments will be able to reduce the tremendous financial costs of this chronic disease.

Spouses of persons with dementia: their healthcare problems, utilization, and costs

Spouses of persons with dementia (PWD) often experience poor health outcomes related to the experience of living with the afflicted spouse. Using the Anderson and Aday Healthcare Utilization Model, we conducted a retrospective review of an administrative database from a private healthcare insurer to compare health problems that precipitate utilization, patterns of utilization, and costs of care of spouses of PWD (n = 979) to those of spouses of persons without dementia (n = 979). Spouses of PWD were treated for more anxiety disorders (OR = 2.97; 95% CI = 1.63-5.44), falls (OR = 7.72; 95% CI = 2.73-21.84), rheumatologic diseases (OR = 2.5; 95% CI = 1.24-5.06), and diabetes with no complications (OR = 1.53; 95% CI = 1.06-2.22), but less pneumonia (OR =.55; 95%; CI =.35-.88) than comparison spouses. Spouses of PWD had a higher number of emergency room (ER) visits (p =.01). There were no differences in costs between the groups. The findings can be used to develop interventions for spouses of PWD.

Dementia and serious coexisting medical conditions: a double whammy

Research-based information about the prevalence of other serious medical conditions in people with dementia has become available only recently, and the true prevalence is not known, primarily because many people with dementia do not have a diagnosis. The existing information is sufficient, however, to show that these other conditions are common in people with dementia. It is also clear that coexisting medical conditions increase the use and cost of health care services for people with dementia, and conversely, dementia increases the use and cost of health care services for people with other serious medical conditions. Nurses and other healthcare professionals should expect to see these relationships in their elderly patients. They should know how to recognize possible dementia and assess, or obtain an assessment of, the patient's cognitive status. They should expect the worsening of cognitive and related symptoms in acutely ill people with dementia and try to eliminate factors that cause this worsening, to the extent possible, while assuring the family that the symptoms are likely to improve once the acute phase of illness or treatment is over. Families, nurses, and other health care professionals are challenged by the complex issues involved in caring for a person with both dementia and other serious medical conditions. Greater attention to these issues by informed and thoughtful clinicians will improve outcomes for the people and their family and professional caregivers.

Patterns of Presentation, Diagnosis, and Treatment in Older Patients with Colon Cancer and Comorbid Dementia

OBJECTIVES

To estimate patterns of colon cancer presentation, diagnosis, and treatment according to history of dementia using National Cancer Institute (NCI) Surveillance, Epidemiology, and End-Result (SEER) Medicare data.

DESIGN

Population-level cohort study.

SETTING

NCI's SEER-Medicare database.

PARTICIPANTS

A total of 17,507 individuals aged 67 and older with invasive colon cancer (Stage I-IV) were identified from the 1993-1996 SEER file. Medicare files were evaluated to determine which patients had an antecedent diagnosis of dementia.

MEASUREMENTS

Parameters relating to the cohort's patterns of presentation and care were estimated using logistic regressions.

RESULTS

The prevalence of dementia in the cohort of newly diagnosed colon cancer patients was 6.8% (1,184/17,507). Adjusting for possible confounders, dementia patients were twice as likely to have colon cancer reported after death (i.e., autopsy or death certificate) (adjusted odds ratio (AOR)=2.31, 95% confidence interval (CI)=1.79-3.00). Of those diagnosed before death (n=17,049), dementia patients were twice as likely to be diagnosed noninvasively than with tissue evaluation (i.e., positive histology) (AOR=2.02 95% CI=1.63-2.51). Of patients with Stage I -III disease (n=12,728), patients with dementia were half as likely to receive surgical resection (AOR=0.48, 95% CI=0.33-0.70). Furthermore, of those with resected Stage III colon cancer (n=3,386), dementia patients were 78% less likely to receive adjuvant 5-fluorouracil (AOR=0.22, 95% CI=0.13-0.36).

CONCLUSION

Although the incidences of dementia and cancer rise with age, little is known about the effect of dementia on cancer presentation and treatment. Elderly colon cancer patients are less likely to receive invasive diagnostic methods or curative-intent therapies. The utility of anticancer therapies in patients with dementia merits further study.

Out-of-pocket health care expenditures among older Americans with dementia

The number of older individuals with dementia will likely increase significantly in the next decades, but there is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by cognitively impaired individuals and their families. We used data from the 1993 and 1995 Asset and Health Dynamics Study, a nationally representative longitudinal survey of older Americans, to determine the OOPE for individuals with and without dementia. Dementia was identified in 1993 using a modified version of the Telephone Interview for Cognitive Status for self-respondents, and proxy assessment of memory and judgment for proxy respondents. In 1995, respondents reported OOPE over the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. The adjusted mean annual OOPE was 1,350 US dollars for those without dementia, 2,150 US dollars for those with mild/moderate dementia, and 3,010 US dollars for those with severe dementia (p < 0.01). Expenditures for hospital/nursing home care (1,770 per year US dollars) and prescription medications (800 per year US dollars) were the largest OOPE components for those with severe dementia. We conclude that dementia is independently associated with significantly higher OOPE for medical care compared with those with normal cognitive function. Severe dementia is associated with a doubling of OOPE, mainly due to higher payments for long-term care. Given that the number of older Americans with dementia will likely increase significantly in the coming decades, changes in public funding aimed at reducing OOPE for both long-term care and prescription medications would have considerable impact on individuals with dementia and their families.

The economic benefits of acetylcholinesterase inhibitors for patients with Alzheimer disease and associated dementias

Most cost-effectiveness studies using simulation modeling have demonstrated that donepezil, rivastigmine, and galantamine are cost effective for the treatment of mild-to-moderate Alzheimer disease (AD). These conclusions are in large part based on the assumption that improvement in cognitive status, or prevention of cognitive and functional decline, reduces the amount of time patients spend institutionalized or receiving other full-time care. However, as discussed in this article, outcomes besides delay to institutionalization affect the costs of AD. In reviews of utilization data from Medicare and managed care organizations, it was noted that hospitalization and post acute care in skilled nursing facilities accounted for the largest amount of excess direct costs, even among patients with mild or moderate AD. These utilization reviews also suggest that many patients with AD and related dementias require inpatient care because they are not able to self-manage comorbid conditions. The improvements in cognitive status and daily functioning associated with acetylcholinesterase inhibitor (AChEI) therapy are expected to translate into improved management of comorbidities and reduced caregiver burden, thus reducing the total cost of care. To confirm these and other economic benefits of AChEIs, pharmacoeconomic outcomes should be evaluated routinely as part of randomized, controlled trials and through well-controlled observational studies of AD patients in community and institutional settings.

Cost effects of a specialized care center for people with Alzheimer's disease

A retrospective cohort control study of three populations, 65 years of age or older, at the same institution estimated the incremental cost of Alzheimer's disease (AD). The AD population of the ambulatory Alzheimer's Disease Center (ADC) (n = 640) was matched by age, gender, ethnicity, and address to one with AD from the general internal medicine practice (AD-GM) (n = 419) and to a control group without AD (n = 5331)from the same general medicine practice. Medicare costs of all care for all diagnoses were obtained for 1998 and 1999. Mean per person annual Medicare costs were $19,418 for ADC, $18, 753 for AD-GM, and $12,085 for the control group. Incremental cost for ADC population was $7,333 and $6,668 for AD-GM population compared with the control group. Incremental cost was $665 (9.1 percent) higher for ADC than AD-GM. Higher non-AD hospitalizations and length of stay (LOS) by AD populations were the main cost drivers.

Dementia Assessment in Primary Care: Results From a Study in Three Managed Care Systems

BACKGROUND

Prior research has found that dementia is often undiagnosed in primary care, but there has been limited research on whether physicians respond to symptoms, behaviors, or other events that may be indicators of dementia.

METHODS

A cross-sectional cohort study design was used to screen 553 patients aged 75 years or older for dementia in 3 managed health care systems in Portland, Oregon. For participants determined to be cognitively impaired, their medical charts were reviewed to determine if they had experienced adverse events, had been clinically evaluated for possible dementia, had received a diagnosis of dementia, or had been offered treatment.

RESULTS

Nearly 43% of participants were identified as cognitively impaired: 29.7% were classified as mildly cognitively impaired (MI) and 13.7% as moderately to severely cognitively impaired (MSI). Eighteen percent of the MI group and 34.8% of the MSI group had evidence in their medical chart of having been clinically evaluated for dementia. None of the MI group and only 4.3% of the MSI group had been offered a cholinesterase inhibitor. Nearly two thirds (61.6%) of the MI and three fourths (75.4%) of the MSI participants had experienced 1 or more adverse events. Of those who had experienced adverse events, less than one quarter (23.7%) in the MI group and less than one half (44.2%) in the MSI group had received a clinical evaluation for dementia.

CONCLUSIONS

These findings suggest the need for greater attention by primary care physicians to the cognitive functioning of older patients, especially patients who experience adverse events that may be indicators of dementia.

The Relationship Between a Dementia Diagnosis, Chronic Illness, Medicare Expenditures, and Hospital Use

OBJECTIVES

To determine whether dementia increases medical expenditures, the probability of hospitalization, and potentially preventable hospitalization, controlling for variables including age and comorbidity.

DESIGN

Cross-sectional analysis of 1 year of claims data comparing usage by patients with claims for dementia with usage by those without dementia.

SETTING

A nationally representative 5% random sample of Medicare beneficiaries in 1999.

PARTICIPANTS

Medicare beneficiaries aged 65 and older with fee-for-service Medicare Parts A and B coverage for 1999 (N=1,238,895; dementia patients n=103,512).

MEASUREMENTS

Per capita expenditures, rate of all-cause hospitalization, rate of preventable hospitalization as defined using ambulatory-care sensitive condition (ACSC) admissions, and dementia identified using International Classification of Diseases, 9th Edition, codes 290, 294, and 331.

RESULTS

Prevalence of dementia was 8.3%. In a model of expenditures in those who survived the year adjusting for age, sex, race, and comorbidity, dementia was associated with an incremental cost of 6,927 US dollars, or 3.3 times greater total expenditures than in nondementia patients (P<.001), with higher expenditures for each specific type of Medicare service. Hospitalization accounted for 54% of adjusted costs. The adjusted odds of hospitalization associated with dementia were 3.68 (95% confidence interval (CI)=3.62-3.73) and adjusted odds of ACSC hospitalization were 2.40 (95% CI=2.35-2.46). In those who died, the associations were positive but of smaller magnitude.

CONCLUSION

In a nationally representative sample, higher Medicare expenditures associated with a diagnosis of dementia are in large part due to increased hospitalization. Further study is needed into the factors associated with high rates of hospitalization in dementia patients including aspects of ambulatory management that may be improved.

The Needs of the Caregiver in the Long-Term Treatment of Alzheimer Disease

The long-term well-being of caregivers should be included as part of the treatment of patients with Alzheimer disease (AD). Throughout the process of caring for patients with AD, caregivers frequently experience social, emotional, physical, and financial losses, which become more significant as the disease progresses. Minimizing these losses is a goal in the overall management of AD. Successful treatment of the patient has been shown to positively impact quality of life for the caregiver. Randomized, controlled studies of acetylcholinesterase inhibitors (AChEIs) have demonstrated the effectiveness of these agents in stabilizing cognitive function and delaying behavioral symptoms. Moreover, a decrease in the incidence of nursing home placement has been associated with this therapy. The growing burden of AD on families and society as a whole warrants the investigation of ways to minimize the impact of AD. AChEIs play an important role in this effort. Further studies are needed to more closely examine the impact of specific AChEIs on caregiver burden.

The Increasing Burden of Alzheimer Disease

Alzheimer disease is a progressive degenerative disease that affects cognition, the ability to perform activities of daily living, and behavior. Cognitive, behavioral, and functional decline associated with progressive Alzheimer disease places a considerable burden on caregivers and the health care system. Earlier detection, better diagnosis, earlier intervention, and increased treatment may help reduce this burden.

A comprehensive study of gray matter loss in patients with Alzheimer's disease using optimized voxel-based morphometry

Voxel-based morphometry (VBM) has already been applied to MRI scans of patients with Alzheimer's disease (AD). The results of these studies demonstrated atrophy of the hippocampus, temporal pole, and insula, but did not describe any global brain changes or atrophy of deep cerebral structures. We propose an optimized VBM method, which accounts for these shortcomings. Additional processing steps are incorporated in the method, to ensure that the whole spectrum of brain atrophy is visualized. A local group template was created to avoid registration bias, morphological opening was performed to eliminate cerebrospinal fluid voxel misclassifications, and volume preserving modulation was used to correct for local volume changes. Group differences were assessed and thresholded at P < 0.05 (corrected). Our results confirm earlier findings, but additionally we demonstrate global cortical atrophy with sparing of the sensorimotor cortex, occipital poles, and cerebellum. Moreover, we show atrophy of the caudate head nuclei and medial thalami. Our findings are in full agreement with the established neuropathological descriptions, offering a comprehensive view of atrophy patterns in AD.

Cost of illness of Alzheimer's disease: how useful are current estimates?

PURPOSE

The goal of this literature review was to determine the validity and policy relevance of recent estimates from many countries of Alzheimer's disease (AD) costs.

DESIGN AND METHODS

We searched Medline and other databases for English-language peer-reviewed journals on total, direct, indirect, and per case cost of AD that used 1985-2000 data. We adjusted costs of U.S. studies for inflation. We adjusted non-U.S. studies by that country's medical cost inflation rate and purchasing power parity (PPP).

RESULTS

Of 71 studies identified, 21 met all criteria for inclusion. Annual inflation adjusted U.S. total costs of AD varied from $5.6 billion to $88.3 billion. AD total per case (direct and indirect) costs varied from $1,500 to $91,000; indirect/family costs varied from $3,700 to $21,000. Among non-U.S. studies, AD annual adjusted per case costs varied from PPP $2,300 to PPP $30,000. Cost variation was due to diverse study methods, data sources, services included, and lack of clear differentiation between cost of AD and cost of caring for people with AD.

IMPLICATIONS

The cost of AD is high, although reliable estimates are not available. Costs are likely to rise given expected demographic shifts in all countries. The widely variable cost estimates call into question the real costs of Alzheimer's disease and their applicability to policy initiatives.

Long-term cholinesterase inhibitor therapy for Alzheimer's disease: implications for long-term care

As the population ages and Alzheimer's disease (AD) becomes more prevalent, nursing facilities will be faced with managing more AD patients than in previous decades. Managing this population will pose a significant challenge for the resources of long-term care facilities. In short- and long-term studies, cholinesterase (ChE) inhibitor treatment has been shown to benefit the symptoms of mild to moderate AD. Donepezil trials have extended this finding to patients with moderate to severe AD as well as the more severe symptoms of AD patients residing in nursing home settings. Results from long-term ChE inhibitor trials and the benefits that may be gained by treating AD patients residing in nursing facilities are presented.

Health care utilization in dementia patients with psychiatric comorbidity

PURPOSE

The purpose of this research was to determine if differences in service use exist between dementia patients with and without psychiatric comorbidity.

DESIGN AND METHODS

A retrospective cohort study was conducted on all Veterans Affairs (VA) beneficiaries seen at the Houston Veterans Affairs Medical Center with a VA Outpatient Clinic File diagnosis of dementia in 1997. The primary dependent measure was amount of Houston VA health service use from study entry until the end of fiscal year 1999 or until death.

RESULTS

Of the 864 dementia patients in the identified cohort, two thirds had a comorbid psychiatric diagnosis. Examination of 2-year health service use revealed that, after adjusting for demographic and medical comorbidity differences, dementia patients with psychiatric comorbidity had increased medical and psychiatric inpatient days of care and more psychiatric outpatient visits compared with patients without psychiatric comorbidity.

IMPLICATIONS

Further understanding of the current health service use of dementia patients with psychiatric comorbidity may help to establish a framework for considering change in the current system of care. A coordinated system of care with interdisciplinary teamwork may provide both cost-effective and optimal treatment for dementia patients.

Pharmacoeconomics of cholinesterase inhibitors in the treatment of Alzheimer's disease

Cholinesterase inhibitors constitute one of few treatment options available for Alzheimer's disease, the most common cause of dementia. The modest effects and relatively high acquisition costs of these drugs make the health economics of dementia an important subject of study. Simulation models can be used to bring together existing data and make predictions of the long-term cost effectiveness of treatment. Most models have been built around cognitive function as a key parameter based on the observed relationship between cognitive function and costs of care. Patients with more severe disease attain higher total costs of care. Also, these patients have a higher share of formal care costs than do patients with mild disease, who are usually looked after by informal caregivers. The valuation of unpaid care is controversial, and the choice of method may affect results considerably. Another important issue is the measurement of health-related QOL in patients with Alzheimer's disease. The few existing studies have used proxy respondents to elicit utility weights in different disease states; however, this methodology has not been validated. It is likely that the increased drug costs incurred by the use of cholinesterase inhibitors will be offset (at least partly) by savings in other healthcare costs. However, these results should be viewed as preliminary, since we are still awaiting data from long-term follow-up studies. Also, the value of treatment for patients and caregivers in terms of QOL improvements has yet to be established.

Resource utilisation and cost analysis of memantine in patients with moderate to severe Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) is a devastating illness that causes enormous emotional stress to affected families and is associated with substantial medical and nonmedical costs.

OBJECTIVE

To determine the effects of 28 weeks of memantine treatment for patients with AD on resource utilisation and costs.

STUDY DESIGN AND METHODS

Multicentre, prospective, double-blind, randomised, placebo-controlled clinical trial performed in the US. The Wilcoxon-Mann-Whitney test was used to examine the resource utilisation variables and logistic regression models were used for multivariate resource utilisation analyses. Analysis of covariance (ANCOVA) models (log and non-log) were computed to examine costs from a societal perspective. All costs were calculated in 1999 US dollars.

STUDY POPULATION

Outpatients with moderate to severe AD. Overall, 252 patients received randomised treatment, and 166 patients (placebo n = 76, memantine n = 90) formed the treated-per-protocol (TPP) subset for the health economic analyses, on which the main cost analysis was based.

MAIN OUTCOME MEASURE

Resource Utilisation in Dementia (RUD) scale, measuring patient and caregiver resource utilisation, and various sources for cost calculations.

RESULTS

Controlling for baseline differences between the groups, significantly less caregiver time was needed for patients receiving memantine than for those receiving placebo (difference 51.5 hours per month; 95% CI -95.27, -7.17; p = 0.02). Analysis of residential status also favoured memantine: time to institutionalisation (p = 0.052) and institutionalisation at week 28 (p = 0.04 with the chi-square test). Total costs from a societal perspective were lower in the memantine group (difference dollars US 1089.74/month [non-overlapping 95% CI for treatment difference -1954.90, -224.58]; p = 0.01). The main differences between the groups were total caregiver costs (dollars US-823.77/month; p = 0.03) and direct nonmedical costs (dollars US-430.84/month; p = 0.07) favouring memantine treatment. Patient direct medical costs were higher in the memantine group (p < 0.01), mainly due to the cost of memantine.

CONCLUSION

Resource utilisation and total health costs were lower in the memantine group than the placebo group. The results suggest that memantine treatment of patients with moderate to severe AD is cost saving from a societal perspective.

Cognitive function and acute care utilization

OBJECTIVES

Little is known about variation in cognitive function across the aged population, or how use and costs of health care vary with cognitive impairment. This study was designed to create a typology of cognitive function in a nationally representative sample, and evaluate acute care use in relation to cognitive function, holding constant confounding factors. By including proxy assessments of cognitive function, this is the first study to include individuals unable to respond themselves.

METHODS

We analyzed the baseline year of the Asset and Health Dynamics Among the Oldest Old (AHEAD) survey, sponsored by the National Institute on Aging, to create three levels of cognitive function, using direct measures for self-respondents (n = 6,651) and proxy evaluations for the others (n = 792). We used a two-part model to predict the likelihood of using various health services and to evaluate intensity of care among users.

RESULTS

Sixteen percent, 64%, and 20% of the sample fell into the low, moderate, and high cognitive function groups, respectively, that differed significantly on almost all demographic and health status measures, and some utilization measures. Controlling for other health and functional status measures, lower cognitive function had a significant and negative effect on outpatient services, but did not affect hospital use directly.

DISCUSSION

Lower cognitive function may be a barrier to outpatient care, but these analyses should be repeated using administrative use and cost data.

The costs of vascular dementia: a comparison with Alzheimer's disease

OBJECTIVES

To estimate the costs of Medicare patients with vascular dementia (VaD). To compare the costs of VaD to Alzheimer's disease (AD) and controls without dementia.

METHODS

The study samples were drawn from community-dwelling patients in a large Medicare managed care organization (MCO) operating in the Northeast region of the USA. Costs for three study groups were contrasted in the study: 240 cases with vascular dementia (VaD), 1,366 cases with Alzheimer's disease (AD), and 19,300 controls without dementia. Costs were estimated from medical and pharmacy claims data. Estimated cost differences are controlled for age, gender, and comorbid conditions using regression analysis.

RESULTS

VaD patients accounted for 6% of all dementia patients identified in the health plan. VaD patients had substantially higher prevalence rates for 10 cardiovascular conditions compared with AD patients and controls. Annual costs for VaD patients were US$6,797 greater than AD patients. Compared with controls, costs were US$10,545 higher for VaD patients and US$3,748 higher for AD patients. Higher costs for VaD and AD patients relative to controls were largely attributable to higher inpatient costs.

CONCLUSIONS

Annual medical costs for VaD patients were substantially higher than costs for patients with AD and control patients without dementia. The high cost of VaD patients suggests a need to improve medical management and treatment of these patients to optimize patient outcomes and medical costs.

Optimizing coding and reimbursement to improve management of Alzheimer's disease and related dementias

The objectives of this study were to review the diagnostic, International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM), diagnosis related groups (DRGs), and common procedural terminology (CPT) coding and reimbursement issues (including Medicare Part B reimbursement for physicians) encountered in caring for patients with Alzheimer's disease and related dementias (ADRD); to review the implications of these policies for the long-term clinical management of the patient with ADRD; and to provide recommendations for promoting appropriate recognition and reimbursement for clinical services provided to ADRD patients. Relevant English-language articles identified from MEDLINE about ADRD prevalence estimates; disease morbidity and mortality; diagnostic coding practices for ADRD; and Medicare, Medicaid, and managed care organization data on diagnostic coding and reimbursement were reviewed. Alzheimer's disease (AD) is grossly undercoded. Few AD cases are recognized at an early stage. Only 13% of a group of patients receiving the AD therapy donepezil had AD as the primary diagnosis, and AD is rarely included as a primary or secondary DRG diagnosis when the condition precipitating admission to the hospital is caused by AD. In addition, AD is often not mentioned on death certificates, although it may be the proximate cause of death. There is only one ICD-9-CM code for AD-331.0-and no clinical modification codes, despite numerous complications that can be directly attributed to AD. Medicare carriers consider ICD-9 codes for senile dementia (290 series) to be mental health codes and pay them at a lower rate than medical codes. DRG coding is biased against recognition of ADRD as an acute, admitting diagnosis. The CPT code system is an impediment to quality of care for ADRD patients because the complex, time-intensive services ADRD patients require are not adequately, if at all, reimbursed. Also, physicians treating significant numbers of AD patients are at greater risk of audit if they submit a high frequency of complex codes. AD is grossly undercoded in acute hospital and outpatient care settings because of failure to diagnose, limitations of the coding system, and reimbursement issues. Such undercoding leads to a lack of recognition of the effect of AD and its complications on clinical care and impedes the development of better care management. We recommend continuing physician education on the importance of early diagnosis and care management of AD and its documentation through appropriate coding, expansion of the current ICD-9-CM codes for AD, more appropriate use of DRG coding for ADRD, recognition of the need for time-intensive services by ADRD patients that result in a higher frequency of use of complex CPT codes, and reimbursement for CPT codes that cover ADRD care management services.

The accuracy of medicare claims data in identifying Alzheimer's disease

We linked Medicare claims data to information on 417 patients with a clinical diagnosis of Alzheimer's disease in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) to determine what proportion of them were identified as having Alzheimer's disease (AD) in Medicare claims records. Seventy-nine percent of these patients were identified as having AD using 5 years of claims data; 87% were identified as demented when a broader set of ICD-9-CM codes was used. An Anderson-Gill counting process approach was used to model the "hazard" of patients being identified as having AD in Medicare claims data. CERAD patients with mild dementia were less likely to be identified in the claims data as having AD. Once identified in Medicare claims as having AD, patients were more likely to be so identified again. When using only the physician supplier and institutional outpatient files, approximately 75% of CERAD patients were identified as having AD; hospital files used alone identified less than one-third (29%) of the CERAD patients as having AD. The data indicate that at least 3 consecutive years of physician supplier and physician outpatient claim files should be used to identify Medicare beneficiaries with AD using Medicare claims.

Effect of Alzheimer disease on the cost of treating other diseases

The authors' objective is to determine the effect of diagnosed Alzheimer disease (AD) on cost to Medicare of treating other diseases. Using the 1994 National Long-Term Care Survey merged with Medicare claims and death data, the authors assessed the relative cost to Medicare of covering beneficiaries over 1994-1995 with diagnosed AD relative to other elderly population. They focused on hospitalizations during 1994-1995 for hip fracture, stroke, coronary heart disease, congestive heart failure, and pneumonia. The authors determined whether differences in Medicare payments by AD status mainly reflected differences in rates of occurrence of hospitalizations for the five primary diagnoses, other primary diagnoses, or death during 1994-1995 or in spending given the adverse events. During 1994-1995, an average of $15,700 was spent by Medicare, per person, for those with diagnosed AD, nearly twice the amount spent on others. The difference in Medicare payments was attributable to more adverse events occurring to AD group. Such persons had higher death rates than other elderly population (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.07-1.62), higher hospitalization rates for hip fracture (OR, 1.96; 95% CI, 1.34-2.87), stroke (OR, 1.71; 95% CI, 1.10-2.68), pneumonia (OR, 1.46; 95% CI, 1.07-1.99), and for other reasons than the five conditions (OR, 1.65; 95% CI, 1.38-1.98), but they also had lower hospitalization rates for the cardiac diseases. There were no differences in Medicare payments according to AD diagnosis, controlling for frequency of deaths, hospitalizations, and other factors. Persons with diagnosed AD cost Medicare more because of more adverse health events rather than in intensity of care, given event occurrence.

Discourse-derived perspectives: differentiating among spouses' experiences of caregiving

A method of constant comparative analysis was used to code open-ended interviews with 132 spouse caregivers regarding their experiences in caregiving. Results of this analysis yielded 69 qualitative code categories. We used these categories to compare the caregivers on several groupings that the literature has identified as providing meaningful ways to differentiate among caregivers. We used the qualitative responses to compare the caregivers by caregiver gender care-recipient dementia severity, and duration of caregiving. Results partly confirmed previous findings that wife caregivers are more distressed than husbands, but the results also indicated these caregivers were more similar than dissimilar The other analyses likewise indicated greater similarities than dissimilarities in the caregiving experience. We next continued the analysis and, using the coding categories as a springboard, identified four distinct patterns for construction of the meaning of the caregiving experience in the caregivers' discourse. These discourse-derived framing categories, applicable in about three-quarters of the caregivers, offered other ways to distinguish among caregivers. Further analysis of these robust groupings' showed important differences among the groups. These framing categories suggest ways to differentiate among caregivers, based on their perception of their role in the caregiving situation, ways that might point the way to intervention strategies for each of the groupings.

The costs of caring: medical costs of Alzheimer's disease and the managed care environment

This review summarizes the medical costs associated with Alzheimer's disease (AD) and related dementias, as well as the payers responsible for these medical costs in the US health care system. It is clear from this review that AD and related dementias are associated with substantial medical costs. The payers responsible for a majority of these costs are families of patients with AD and the US government through the Medicare and Medicaid programs. In an attempt to control expenditures, Medicare and Medicaid have turned to managed care principles and managed care organizations. The increase in "managed" dementia care gives rise to several potential problems for patients with AD, along with many opportunities for systematic improvement in the quality of dementia care. Evidence-based disease management programs provide the greatest opportunities for improving managed dementia care but will require the development of dementia-specific quality of care measures to evaluate and continually improve them.

Clinical and economic factors in the treatment of behavioural and psychological symptoms of dementia

The prevalence of behavioural and psychological symptoms of dementia (BPSD) exceeds 50%. They cause distress to patients and caregivers, increase resource utilisation of various kinds, and form a high risk for accelerated psychiatric care through institutionalisation. Although evidence for current pharmacological treatment is not strong and the construct of BPSD is still not very clear, future aspects of treatment of BPSD may be positive. If we look at overall success rates of the antipsychotics, the traditional antipsychotics have the highest combined success rate of 63.1%, whereas the novel antipsychotics have an overall success rate of 56.1%. Haloperidol is the drug with the highest success rate of 65.4%, although this drug is associated with parkinsonian adverse drug reactions. Newer antipsychotics show promise in treating BPSD, but more convincing evidence (e.g. from randomised clinical trials) is required. We provide an overview of the clinical, epidemiological and economic aspects of BPSD and a review of the available literature on their pharmacological treatment. Although only 1 pharmacoeconomic study has been conducted on BPSD, it seems likely that these manifestations drastically increase the burden of dementia.

Healthcare utilization and costs in managed care patients with Alzheimer's disease during the last few years of life

OBJECTIVES

To learn whether managed care patients with Alzheimer's disease (AD) are more or less costly to care for than patients with other forms of dementia or patients without dementia during the last few years of life.

DESIGN

Case control study.

SETTING

A health maintenance organization base population.

PARTICIPANTS

Three groups of subjects (mean age 85) who were deceased members of a dementia registry obtained from a health maintenance organization base population: 263 subjects with clinically diagnosed probable AD, 133 subjects with other forms of dementia, and 100 cognitively intact controls.

MEASUREMENTS

Utilization records were examined for the 3 years preceding death.

RESULTS

In all subcategories and in aggregate, utilization and costs of care were either similar or lower for patients with AD than for the other groups, even after controlling for age, gender, and comorbidity.

CONCLUSIONS

Persons with AD do not incur higher costs than persons with other types of dementia or age-matched persons without dementia in a mature health maintenance organization during the last few years of life, when utilization is likely to be highest.

Economic considerations of Alzheimer's disease and related disorders

Economic analyses of geriatric syndromes are seldom performed. However, demographic and epidemiological imperatives have led to significant interest in the evaluation of AD-related costs. Over 300 papers devoted to economic considerations of Alzheimer's disease have been published in peer-reviewed journals, within the last five years. In these papers, the chosen perspective (costs to society or to specific payers) is important. Analytical methods are still evolving and remain complex. Unresolved methodological issues will need to be addressed to further our understanding of long-term economic consequences. At present, it is clear that diagnostic and drug costs are low compared to the major cost of institutionalization. Thus, directing efforts at early diagnosis and delaying nursing home placement are two key cost-containment interventions. In this respect, the need to support informal care should not be underestimated.

Alzheimer's disease: insights from epidemiology

While a complete understanding of the pathogenesis of Alzheimer's disease (AD) remains elusive, many conclusions can be drawn from the numerous epidemiological studies undertaken to date. Prevalence and incidence estimates show consistency, following a roughly exponential pattern with a doubling of both parameters roughly every five years after age 65. Roughly 7% of the population aged 65 and over has AD. The clinical course of the disease is reasonably well established and mortality rates rise with increasing levels of cognitive deficit. Four risk factors for AD are firmly established: increasing age, the presence of the apolipoproteinE-epsilon4 allele, familial aggregation of cases, and Down's syndrome. Numerous other associations have been shown in some studies, but not in others. For example, women generally appear at higher risk than men, as do people with lower levels of education; depression is probably prodromal; head injury is an established risk factor, and may interact with the apoE gene; several occupational exposures appear hazardous, and exposure to aluminum in the water supply confers excess risk. Hypertension and other vascular symptoms appear to predispose to AD, which is now seen as nosologically closer to vascular dementia than was previously believed. Several apparently protective factors have been identified, although preventive trials based on these have so far shown minimal effectiveness. The use of non-steroidal anti-inflammatory drugs to treat arthritis is associated with a reduced risk of AD, as is estrogen use by post-menopausal women. Physical activity appears beneficial, as does a diet with high levels of vitamins B6, B12 and folate. while red wine in moderate quantities appears protective. This review concludes with a discussion of the strengths and limitations of current epidemiological methods for studying Alzheimer's disease.

Dementia family caregiver training: affecting beliefs about caregiving and caregiver outcomes

OBJECTIVES

Family caregiving is an integral part of the care system for persons with dementing disorders, such as Alzheimer's disease. This study tested role-training intervention as a way to help family caregivers appreciate and assume a more clinical belief set about caregiving and thereby ameliorate the adverse outcomes associated with caregiving.

DESIGN

Training effectiveness was tested in a trial in which family care receiver dyads were randomly assigned to training beginning immediately or were placed in a wait-list control group and assigned to receive training in 5 to 6 months, following completion of data collection.

SETTING

A community-based 14-hour training program provided in seven weekly 2-hour sessions. The training program curriculum was built on a stress and coping theory base. Recruitment and randomization were ongoing. Programs were begun every 2 months over a two and one half-year period for a total of 16 programs.

PARTICIPANTS

Community health and social service agencies referred primary caregivers and at least one other family member of community-dwelling persons with dementia to participate.

MEASUREMENTS

Data reported in this paper were gathered from each participating family at entry to the study and 5 months later. Standard measures of beliefs about caregiving, burden, depression, and reaction to care receiver behavior were administered to caregivers. A standard measure of mental status was administered to the person with dementia and standardized instruments were used to gather information from caregivers concerning care receivers' behavior and abilities to perform activities of daily living (ADLs).

RESULTS

Data were analyzed from 94 caregiver/care receiver dyads with complete sets of data. Treatment and control caregivers and care receivers were similar at baseline, and care receivers in both groups declined similarly over the 5-month period. Significant within-group improvements occurred with treatment group caregivers on measures of beliefs about caregiving (P = .044) and reaction to behavior (P = .001). When outcomes were compared, treatment group caregivers were significantly different (in the expected direction) from those in the control group on measures of the stress mediator, beliefs (P = .025), and key outcomes, response to behavior (P = .019), depression (P = .040), and burden (P = .051). There was a significant positive association between the strengthened mediator, the caregivers' having less-emotionally enmeshed beliefs about caregiving roles and responsibilities, and the outcome, namely improvements in burden (P = .019) and depression (P = .007).

CONCLUSION

A caregiver training intervention focused on the work of caregiving and targeted at knowledge, skills, and beliefs benefits caregivers in important outcome dimensions. The results suggest the benefits of providing information, linkage, and role coaching to dementia family caregivers.

Medicare expenditures associated with Alzheimer disease

This study uses 4 years of data from the Medicare Current Beneficiary Survey to compare the use of Medicare covered services for persons who report having a diagnosis of dementia or Alzheimer disease with those who do not, adjusting for the prevalence of comorbidities and functional limitations. Although overall rates of Medicare spending are higher for demented persons, when other factors such as functional status are included in the predictive model, there is no consistent relation between the presence of dementia and higher Medicare spending. In some years, dementia was associated with higher adjusted expenditures for community living persons, whereas nursing home residents with Alzheimer disease have lower Medicare expenditures.

Donepezil use in managed Medicare: effect on health care costs and utilization

Donepezil is one of the first effective and well-tolerated medications approved for the treatment of Alzheimer's disease (AD). This study examined the impact of donepezil on the costs of AD in a multisite managed care organization between January 1, 1996, and March 31, 1998. A pretreatment/posttreatment study was conducted using retrospective medical and prescription claims data for 70 individuals with AD and related dementias who were prescribed donepezil. The outcomes of interest were costs during the pretreatment and posttreatment phases, which were categorized as medical, prescription, and combined costs. Per diem costs were adjusted for differences in the duration of follow-up. We found that median per diem medical costs were $1.22 lower in the posttreatment phase than in the pretreatment phase (P = 0.02). Moreover, posttreatment costs were reduced in 6 of 7 service settings, with median per diem savings of $0.77 in outpatient care (P = 0.002) and $0.65 in office visits (P < 0.001). In the posttreatment phase, the median per diem costs for prescriptions and all claims combined were higher by $2.59 (P < 0.001) and $2.11 (P = 0.04), respectively. Donepezil treatment was associated with a decrease in medical costs, particularly in the outpatient components of health care. However, overall costs were increased due to the higher costs of medication. Further pharmacoeconomic studies are needed to determine the exact impact of acetylcholinesterase-inhibitor therapy on the overall costs of care for individuals with dementia.