Financial Presentation of Alzheimer Disease and Related Dementias

A person-centered approach to financial capacity: early memory loss, financial management and decision-making

OBJECTIVES

Previous research has noted that a person-centered approach to financial capacity assessment is feasible. This study of personal finance included a review of 12 months of checking account statements followed by research interviews to investigate income, spending, financial literacy, and financial decision-making. The objective of the study was to determine the convergent validity of excess spending to contextual aspects of financial decision-making, financial literacy, and early memory loss.

METHOD

Participants were 114 adults over the age of 60 who came primarily from two research registries; the Healthier Black Elders registry and the Michigan Alzheimer's Disease Research Center registry. After sharing their checking statements participants completed two telephone interviews. Bivariate and multivariate analyses were used to compare those with no memory loss to the memory loss group, and to determine which measures were significantly related to excess spending.

RESULTS

There was a significant difference in excess spending between those with early memory loss and those with no memory loss. There was a significant difference in financial decision-making risk scores between the groups, as well as on a memory measure and a financial literacy measure. In a hierarchical regression analysis financial decision-making was the only measure significantly related to excess spending.

CONCLUSION

This study documented the convergent validity of person-centered measures of personal spending and financial decision-making with early memory loss. Early memory loss was related to both excess spending and contextual aspects of financial decision-making.

Cognition and Wealth Changes in Mid-to-later Life: A Latent Class Trajectories Approach Using the Health and Retirement Study

ObjectivesTo assess how cognitive trajectories from mid-to-later life relate to wealth change, overall and by mid-life income. Methods: Data were from participants (51-64 years) in the 2000-2018 U.S. Health and Retirement Study who were cognitively healthy at baseline (year 2000; unweighted n = 3821). Longitudinal latent class analyses generated cognitive and wealth trajectories, independently, and multinomial logistic regressions estimated the association between cognitive trajectories and wealth profiles, overall and by median income. Results: We identified three cognitive: cognitively healthy (CH), increasing cognitive impairment (ICI), and increasing dementia (ID) and four wealth profiles: stable wealth loss (SWL), delayed gradual wealth loss (DGWL), stable wealth gain (SWG), and gradual wealth gain (GWG). The ID group had higher probability of being in the SWL group and lower probability of SWG, which was more pronounced in respondents with greater median income. Discussion: Individuals with ID may be vulnerable to wealth loss, particularly for middle-class households.

Perceived Financial Vulnerability, Wealth, and Wealth Change: The Health and Retirement Study

OBJECTIVES

The 6-item Perceived Financial Vulnerability (PFV) scale assesses awareness and psychological vulnerability regarding finances. Prior findings using the Health and Retirement Study (HRS) identified significant associations of PFV with wealth, demographics, and health status. This study examines the relationship between wealth, changes in wealth, and PFV.

METHODS

Data from HRS respondents were analyzed (N = 1,056). Total assets at baseline (2016) and changes in total assets over two waves (2016 to 2018) were stratified into deciles and used as primary predictors of PFV in 2018. Multiple linear regression models examined the influence of demographics, wealth change (linearly and curvilinearly), and baseline wealth on PFV.

RESULTS

Wealth change and baseline wealth were associated with PFV. When controlled for baseline wealth, wealth loss linearly predicted increased PFV.

CONCLUSIONS

These findings support the utility of the PFV. Findings underscore the importance of integrating multifaceted financial and demographic information when conceptualizing subjective financial welfare.

CLINICAL IMPLICATIONS

Financial wellbeing is crucial in older clients and should be assessed over time. The 6-item PFV effectively evaluates contextual aspects of financial decision-making across socioeconomic statuses, making it valuable for clinical assessments.

Alzheimer's disease biomarkers and the tyranny of treatment

Advances in treatment are changing not only the therapeutic options for patients with Alzheimer's disease; they're also changing their diagnostic options. Technologies to detect amyloid such as PET imaging and blood or CSF testing now have a central role in Alzheimer's disease care. Notably, this role has been made possible by regulatory approval and coverage by payers of therapies. Access to treatments and the diagnostic tests needed to prescribe them is encourageing but it reveals a problem. These tests are tailored to the needs of the therapies, not to the needs of patients. Patients and families need to understand the causes of their impairments and their prognosis. This requires access to the best available diagnostic tests and this access should not depend on the availability of treatments. These tests should be used to their fullest capacity to inform patients of the causes of their cognitive impairments and their prognosis. Unfortunately, compared to diagnostic testing, treatment options are overvalued. We call this problem the tyranny of treatment.

Somatic and psychiatric comorbidity in people with diagnosed gambling disorder: A Finnish nation-wide register study

BACKGROUND AND AIMS

This is the first nation-wide register study based on a total population sample measuring the gender-specific incidences of chronic diseases and conditions among adults diagnosed with gambling disorder (GD).

DESIGN, SETTING AND PARTICIPANTS

The study used aggregated data for 2011-22 retrieved from the Register of Primary Health Care visits, Care Register for Health Care and Care Register for Social Welfare, including specialized outpatient and inpatient health care, inpatient social care and institutional care and housing services with 24-hour or part-time assistance, set in mainland Finland. Participants comprised people aged 18-90+ years with GD diagnosis [corresponding to pathological gambling, International Classification of Diseases 10th revision (ICD-10) code F63.0, n = 3605; men n = 2574, women n = 1031] and the general population (n = 4 374 192).

MEASUREMENTS

Incidences of somatic diseases and psychiatric disorders were calculated for the people with diagnosed GD and for the general population, separately for women and men.

FINDINGS

After standardizing for age, the incidence of each diagnostic group was systematically higher for people with GD compared with the general population, except for cancer. The highest standardized incidence ratio (SIR) values were for psychiatric disorders [SIR = 234.2; 95% confidence interval (CI) = 226.1-242.4], memory disorders (SIR = 172.1; 95% CI = 119.1-234.8), nervous system diseases (SIR = 162.8; 95% CI = 152.8-173.1), chronic respiratory diseases (SIR = 150.6; 95% CI = 137.6-164.2), diabetes (SIR = 141.4; 95% CI = 127.9-155.5) and digestive diseases (SIR = 134.5; 95% CI = 127.1-142.2).

CONCLUSIONS

In Finland, the incidence of chronic diseases and conditions among people with gambling disorder is higher compared with the general population, apart from cancer.

Medicare Advantage enrollment and outcomes of post-acute nursing home care among patients with dementia

Enrollment in Medicare Advantage (MA) has been rapidly growing. We examined whether MA enrollment affects the outcomes of post-acute nursing home care among patients with Alzheimer's disease and related dementias (ADRD). We exploited year-to-year changes in MA penetration rates within counties from 2012 through 2019. After adjusting for patient-level characteristics and county fixed effects, we found that MA enrollment was not associated with days spent at home, nursing home days, likelihood of becoming a long-stay resident, hospital days, hospital readmission, or 1-year mortality. There was a modest increase in successful discharge to the community by 0.73 percentage points (relative increase of 2.4%) associated with a 10-percentage-point increase in MA enrollment. The results are consistent among racial/ethnic subgroups and dual-eligible patients. These findings suggest an imperative need to monitor and improve quality of managed care among enrollees with ADRD.

Health care utilization before and after a dementia diagnosis in Medicare Advantage versus traditional Medicare

BACKGROUND

Half of all Medicare beneficiaries are enrolled in Medicare Advantage (MA). Many studies document lower care utilization and mortality in MA than traditional Medicare (TM), but evidence for persons with Alzheimer's disease and related dementias (ADRD) is limited.

METHODS

We conducted a retrospective cohort study of 2015-2018 Medicare claims and encounter data for community-dwelling beneficiaries aged 65 and over in TM and MA with an incident ADRD diagnosis in 2017. We compared monthly hospitalization rates and outpatient visits 12 months before and after diagnosis and mortality 1 year from diagnosis. Models adjusted for sociodemographic characteristics and comorbidities. Sensitivity analyses addressed residual confounding using a control group with incident arthritis/glaucoma or excluding MA Special Needs Plans, and potential underreporting by restricting to MA plans with high data completeness.

RESULTS

Among 454,508 beneficiaries diagnosed with ADRD in 2017, 250,837 (55%) were in TM and 203,671 (45%) in MA. Four to 12 months before diagnosis, monthly hospitalizations and outpatient visits were similar in TM and MA. In the diagnosis month, 36.5% of beneficiaries in TM had a hospitalization compared with 25.4% in MA, an adjusted difference of 10.7 percentage points [95% CI: 10.3, 11.1]. Beneficiaries in TM averaged 10.5 outpatient visits in the diagnosis month compared with 8.4 in MA, an adjusted difference of 1.59 visits [95% CI: 1.47-1.70]. Utilization differences narrowed but remained higher in TM for many months. One-year mortality was 27.9% in TM and 22.2% in MA; an adjusted odds ratio of 1.152 [95% CI: 1.135-1.169] for those in TM compared with MA. Controlling for hospitalization in the diagnosis month substantially reduced the mortality difference.

CONCLUSION

Hospitalization rates and outpatient visits increased more after an ADRD diagnosis in TM than MA. One-year post-diagnosis, mortality was not higher in MA than TM but comparisons of quality of life and caregiver burden are needed.

Potential corporate uses of polygenic indexes: Starting a conversation about the associated ethics and policy issues

Some commercial firms currently sell polygenic indexes (PGIs) to individual consumers, despite their relatively low predictive power. It might be tempting to assume that because the predictive power of many PGIs is so modest, other sorts of firms-such as those selling insurance and financial services-will not be interested in using PGIs for their own purposes. We argue to the contrary. We build this argument in two ways. First, we offer a very simple model, rooted in economic theory, of a profit-maximizing firm that can gain information about a single consumer's genome. We use the model to show that, depending on the specific economic environment, a firm would be willing to pay for statistically noisy PGIs, even if they allow for only a small reduction in uncertainty. Second, we describe two plausible scenarios in which these different kinds of firms could conceivably use PGIs to maximize profits. Finally, we briefly discuss some of the associated ethics and policy issues. They deserve more attention, which is unlikely to be given until it is first recognized that firms whose services affect a large swath of the public will indeed have incentives to use PGIs.

The WALLET Study: Financial Decision Making and Key Financial Behaviors Associated with Excess Spending

OBJECTIVES

The Wealth Accumulation and Losses in Later life Early Cognitive Transitions (WALLET) study data was used to examine correlates with excess spending in older adults who do and do not have early memory loss.

METHODS

The WALLET study collected detailed financial information from participants' primary checking account statements (n = 150). Information on participant sociodemographic, health, and disability status, memory functioning, financial decision-making, and financial literacy was also collected. Participants either had no memory problems or early memory loss. Bivariate and multiple regression analyses were conducted.

RESULTS

The early memory loss group had significantly higher excess spending than those with no memory loss. Financial decision-making and higher-risk financial behaviors were also linked to higher excess spending. Early memory loss was no longer statistically significant after accounting for financial stressors and resources.

CONCLUSIONS

The multidimensional nature of financial capacity assessment has long been known. The WALLET study data is unique, however, in that it demonstrates the links between excess spending with decision-making, early memory loss, and a set of specific financial behaviors.

CLINICAL IMPLICATIONS

Real-world assessments of financial management and financial decision-making yield important information about how older adults are managing money and making key financial decisions. Checking account reviews can be used to determine excess spending.

Alzheimer's in the modern age: Ethical challenges in the use of digital monitoring to identify cognitive changes

Pushes toward earlier detection of Alzheimer's disease (AD)-related cognitive changes are creating interest in leveraging technologies, like cellphones, that are already widespread and well-equipped for data collection to facilitate digital monitoring for AD. Studies are ongoing to identify and validate potential "digital biomarkers" that might indicate someone has or is at risk of developing AD dementia. Digital biomarkers for AD have potential as a tool in aiding more timely diagnosis, though more robust research is needed to support their validity and utility. While there are grounds for optimism, leveraging digital monitoring and informatics for cognitive changes also poses ethical challenges, related to topics such as algorithmic bias, consent, and data privacy and security. As we confront the modern era of Alzheimer's disease, individuals, companies, regulators and policymakers alike must prepare for a future in which our day-to-day interactions with technology in our daily life may identify AD-related cognitive changes.

Real World Financial Mismanagement in Alzheimer's Disease, Frontotemporal Dementia, and Primary Progressive Aphasia

Background

Whereas clinical experience in dementia indicates high risk for financial mismanagement, there has been little formal study of real world financial errors in dementia.

Objective

We aimed to compare caregiver-reported financial mistakes among people with Alzheimer's disease, behavioral variant frontotemporal dementia (bvFTD), and primary progressive aphasia (PPA).

Methods

Caregivers reported whether participants with dementia had made financial mistakes within the last year; and if so, categorized these as resulting from: (a) being too trusting or gullible, (b) being wasteful or careless with money, or (c) trouble with memory. In a pre-registered analysis https://archive.org/details/osf-registrations-vupj7-v1), we examined the hypotheses that (1) financial mistakes due to impaired socioemotional function and diminished sensitivity to negative outcomes are more prevalent in bvFTD than in Alzheimer's disease, and (2) financial mistakes due to memory are more prevalent in Alzheimer's disease than in bvFTD. Exploratory analyses addressed vulnerability in PPA and brain-behavior relationships using voxel-based morphometry.

Results

Concordant with our first hypothesis, bvFTD was more strongly associated than Alzheimer's disease with mistakes due to being too trusting/gullible or wasteful/careless; contrary to our second hypothesis, both groups were similarly likely to make mistakes due to memory. No differences were found between Alzheimer's disease and PPA. Exploratory analyses indicated associations between financial errors and atrophy in right prefrontal and insular cortex.

Conclusions

Our findings cohere with documented socioemotional and valuation impairments in bvFTD, and with research indicating comparable memory impairment between bvFTD and Alzheimer's disease.

Using Address Data to Track Household Financial Burden of Disease

The financial burden of illness cannot be correctly characterized without accounting for the impacts across healthy and sick members of a household. Currently, we have very few large, nationally representative data resources to facilitate such work. This paper describes ways to move the field forward through a novel application of address data.

Declines in Wealth Among US Older Adults at Risk of Dementia

This case-control study uses Health and Retirement Study data to examine the trajectories of wealth among US older adults at risk of dementia.

The Long-Term Impacts of Dementia on Preventive Care Utilization and Health Behaviors

Dementia has large impact on individuals' decision making, independent living, and wellbeing. Identifying early signals of dementia risk may offer people more time to prepare for the future, helping to delay the onset or slow the progression of dementia. Using the 1995-2018 waves of Health and Retirement Study, we offer novel evidence on the impacts of dementia on a rich set of preventive care utilization and health behaviors. Leveraging both within- and between-individual variations in an event study design, we characterize long-term dynamic changes in preventive care and health behaviors relative to the incidence of dementia and find early behavioral indicators of the disorder. We show that relative to the group of people who never develop dementia during the study periods, people with dementia have consistent and escalating declines in the use of cholesterol test, dental visit, prostate test and mammogram around the incidence of dementia. Significant declines are also found in physical activities and social engagement. Importantly, we demonstrate that the behavioral changes can occur up to 6 years before the incidence of dementia; and these patterns are absent in other chronic or acute conditions. The results are robust to sample selection, model specification, and the further control of aging and cohort effects. Overall, our findings highlight the salient impact of dementia risk on preventive care utilization and health behaviors, which may increase individuals' vulnerability to health shocks. Detecting early signals of dementia and facilitating targeted interventions are thus called for to prevent individuals from adverse behavioral and health consequences.

Does Consumer Credit Precede or Follow Changes in Cognitive Impairment Among Older Adults? An Investigation in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) Trial

OBJECTIVES

We assessed the relationships between pre- and post-morbid consumer credit history (credit scores, debts unpaid, or in collections) and classification of mild (or greater) cognitive impairment (MCI).

METHODS

Generalized Estimating Equation models assessed pre-and post-morbid credit history and MCI risk among 1740 participants aged 65+ in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study, linked to TransUnion consumer credit data.

RESULTS

Each 50-point increase in credit score was associated with up to 8% lower odds of MCI in the next 3 years. In contrast, new unpaid collections over doubled the odds of having MCI in the next 3 years. MCI was associated with subsequent credit score declines and a 47%-71% greater risk of having a new unpaid collection in the next 4 years.

DISCUSSION

Credit declines may signal risk for future MCI. MCI may lead to financial challenges that warrant credit monitoring interventions for older adults.

Vision difficulty and dementia: economic hardships among older adults and their caregivers

Introduction

Limited research has examined the economic impact of vision difficulty (VD) and dementia on older adults and their caregivers. We aimed to determine whether older adults with VD and/or dementia, and their caregivers, face more economic hardships than their counterparts without VD or dementia.

Methods

We used cross-sectional data from the 2015 National Health and Aging Trends Study (NHATS), a population-based survey of Medicare beneficiaries, linked to their family/unpaid caregivers from the National Study of Caregiving (NSOC). Regression models characterized the association of VD (self-report), dementia (survey and cognitive assessments), and co-occurring VD and dementia with debt, receiving financial help from relatives, government-based Supplemental Nutrition Assistance Program (SNAP), other food assistance, utility assistance, and caregiver financial difficulty.

Results

The NHATS sample included 6,879 community-dwelling older adults (5670 no VD/dementia, 494 VD-alone, 512 dementia-alone, 203 co-occurring VD and dementia). Adults with VD and dementia had higher odds of receiving SNAP benefits (OR = 2.6, 95%CI = 1.4-4.8) and other food assistance (OR = 4.1, 95%CI = 1.8-9.1) than adults without VD/dementia, while no differences were noted for debt, financial help, and utility assistance. Adults with VD-alone had higher odds of debt (OR = 2.1, 95%CI = 1.3-3.2), receiving financial help (OR = 1.7, 95%CI = 1.1-2.5) and other food assistance (OR = 2.7, 95%CI = 1.7-4.3); while adults with dementia-alone had higher odds of debt (OR = 2.8, 95%CI = 1.4-5.5). The NSOC sample included 1,759 caregivers (995 caring for adults without VD/dementia, 223 for VD-alone, 368 for dementia-alone, and 173 for co-occurring VD and dementia). Compared to caregivers of older adults without VD/dementia, caregivers of adults with VD and dementia had higher odds of financial difficulty (OR = 3.0, 95%CI = 1.7-5.3) while caregivers of adults with VD-alone or dementia-alone did not.

Discussion

While older adults with VD- or dementia-alone experienced increased economic hardships, disparities in food assistance were amplified among older adults with co-occurring disease. Caregivers of adults with co-occurring disease experienced more financial difficulty than caregivers of adults with a single or no disease. This study highlights the need for interventions across clinical and social services to support the economic wellbeing of our aging population and their caregivers.

Self-perceived memory is negatively associated with chronic disease awareness: Evidence from blood biomarker data

Background and objectives

Cognitive misperception contributed to poor decision-making; yet their impact on health-related decisions is less known. We examined how self-perceived memory was associated with chronic disease awareness among older Chinese adults.

Research design and methods

Data were obtained from the China Health and Retirement Longitudinal Study. Nationally representative blood biomarkers were collected in 2015 to identify participants' dyslipidemia and diabetes status. Among participants with biomarker identified dyslipidemia or diabetes, disease awareness was defined as self-reported diagnosis of the conditions as of 2018. The association of self-perceived memory with chronic disease awareness was determined by weighted multivariate logistic regressions adjusting for cognitive ability and covariates.

Results

Among 4578 adults aged 60 and over, 1442 and 759 individuals were identified having dyslipidemia and diabetes, with proportions of disease awareness being 38.0% and 58.1%, respectively. The proportions were lower for individuals with better self-perceived memory and those with more impaired cognitive ability, showing opposite patterns. Adjusting for cognitive ability and covariates, self-perceived memory was negatively associated with the dyslipidemia (OR = 0.80, 95%CI: 0.63-1.02) and diabetes (OR = 0.71, 95%CI: 0.55-0.92) awareness. In particular, older adults with the highest level of self-perceived memory had significantly lower disease awareness as compared to those with the lowest level of self-perceived memory (OR = 0.51, 95%CI: 0.28-0.94 for dyslipidemia; and OR = 0.42, 95%CI: 0.21-0.84 for diabetes). The negative association was robust to adjusting for alternative cognitive measures, and was stronger for individuals with rural status, lower education, or living without children.

Discussion and implications

Cognitive misperception poses great challenges to chronic disease awareness. Targeted interventions and supports are needed, particularly for those more disadvantaged.

Treatment preferences among adults with normal cognition and cognitive impairment

BACKGROUND

Although patient participation in treatment decisions is important for preference-concordant care delivery, it is largely unknown how cognitive impairment influences treatment preferences. We investigated whether treatment preferences for the care of serious illness differ between adults with and without cognitive impairment in hypothetical clinical scenarios.

METHODS

Data from the 2018 Health and Retirement Study were used. The sample included 1291 self-respondents (201 respondents with cognitive impairment, and 1090 with normal cognition). We examined treatment preferences for life-extending, limited, and comfort care options in two hypothetical clinical scenarios where the respondent imagines a patient with (1) good physical health with severe cognitive impairment consistent with dementia; and (2) with physical impairment due to a heart attack, but normal cognition. Respondents specified whether they were unsure, or if they would want or not want each treatment option. Linear probability models were used to compare treatment preferences by cognitive status.

RESULTS

Respondents with cognitive impairment were more likely to report that they were unsure about treatment options across both clinical scenarios compared to those with normal cognition. For the limited treatment option, cognitive impairment was associated with a lower rate of expressing a treatment preference by 7.3 (p = 0.070) and 8.5 (p = 0.035) percentage points for dementia and heart attack scenarios, respectively. Among those who articulated preferences, cognitive impairment was associated with a higher rate of preference for life-extending treatment in both dementia (30.1% vs. 20.0%, p = 0.044) and heart attack scenarios (30.0% vs. 20.2%, p = 0.033).

CONCLUSIONS

Compared to those with normal cognition, cognitive impairment was associated with greater uncertainty about treatment preferences and higher rates of aggressive care preferences among those who specified preferences. Further research should assess whether preferences for aggressive care become more common as cognition declines in order to improve preference-concordant care delivery for patients with cognitive impairment.

Rosiridin Attenuates Scopolamine-Induced Cognitive Impairments in Rats via Inhibition of Oxidative and Nitrative Stress Leaded Caspase-3/9 and TNF-α Signaling Pathways

AIM

A monoterpene and bioactive component of the plant Rhodiola rosea (R. rosea), rosiridin has beneficial effects on the human central nervous system and enhances brain function. The goal of this scientific study was to determine if rosiridin might shield rats from neurocognitive problems induced by scopolamine.

METHODS

To track the potential toxicities in rats, the acute toxicity in rats was clarified. Rosiridin at a dose of 10 mg/kg was tested in rats for 14 days. At the conclusion of the investigation, behavioral parameters that were used to identify the rats' cognitive and motor abilities were evaluated. Several biochemical parameters were estimated using the prepared homogenate, including acetylcholine esterase (AChE), choline acetyltransferase (ChAT), radical scavengers produced by the body (Catalase-CAT, superoxide dismutase-SOD, and reduced glutathione-GSH), indicators of oxidative and nitrative burnout, pro-inflammatory (Interleukins- IL-1β, IL-6, interferon gamma IFN-ꝩ, and tumor necrosis factor-TNF-α), and cell apoptosis caspases 3 and 9.

RESULTS AND CONCLUSION

A significant behavioral parameter restoration was seen in the rosiridin-treated group, including reduction in latency time during acquisition and retention trial in the Morris water maze test, and percentage of spontaneous alterations in the y-maze test, when compared to the disease control group that received scopolamine; rosiridin also altered the oxidative stress and neuroinflammatory markers, as well as restoring Ach and ChAT activities and normalizing GSH, SOD, MDA, TNF-α, nitrate, IL-1β, IL-6, IFN-ꝩ, caspases 3 and 9 levels. The results imply that rosiridin limits the effect of scopolamine on rat cognitive function.

Observational study of patient characteristics associated with a timely diagnosis of dementia and mild cognitive impairment without dementia

BACKGROUND

Timely diagnosis of cognitive impairment is a key goal of the National Plan to Address Alzheimer's Disease, but studies of factors associated with a timely diagnosis are limited.

OBJECTIVE

To identify patient characteristics associated with a timely diagnosis of dementia and mild cognitive impairment (MCI).

DESIGN

Retrospective observational study using survey data from the Health and Retirement Study (HRS) from 1995-2016 (interview waves 3-13).

PARTICIPANTS

4,760 respondents with incident dementia and 1,864 with incident MCI identified using longitudinal measures of cognitive functioning.

MAIN MEASURES

Timely or delayed diagnosis based on the timing of a self or proxy report of a healthcare provider diagnosis in relation to respondents first dementia or MCI-qualifying cognitive score, sociodemographic characteristics, health status, health care utilization, insurance provider, and year of first qualifying score.

KEY RESULTS

Only 26.0% of the 4,760 respondents with incident dementia and 11.4% of the 1,864 respondents with incident MCI received a timely diagnosis. Non-Hispanic Black respondents and respondents with less than a college degree were significantly less likely to receive a timely diagnosis of either dementia or MCI than Non-Hispanic White respondents (dementia odds ratio (OR): 0.61, 95% CI: 0.50, 0.75; MCI OR: 0.40, 95% CI: 0.23, 0.70) and those with a college degree (dementia OR for less than high school degree: 0.30, 95% CI: 0.23, 0.38; MCI OR: 0.36, 95% CI: 0.22, 0.60). Respondents that lived alone were also less likely to receive a timely diagnosis of dementia (OR: 0.69, 95% CI: 0.59, 0.81), though not MCI. Timely diagnosis of both conditions increased over time.

CONCLUSIONS

Targeting resources for timely diagnosis of cognitive impairment to individuals from racial and ethnic minorities, lower educational attainment, and living alone may improve detection and reduce disparities around timely diagnosis of dementia and MCI.

Management of Financial Assets by Older Adults With and Without Dementia or Other Cognitive Impairments

This cross-sectional study examines the extent to which older US adults with dementia or cognitive impairments manage their own finances, report difficulty doing so, and own risky financial assets such as stocks and loans.

Comparing the care experiences of Medicare Advantage beneficiaries with and without Alzheimer's disease and related dementias

BACKGROUND

The Medicare Advantage (MA) program is rapidly growing. Limited evidence exists about the care experiences of MA beneficiaries with Alzheimer's Disease and Related Dementia (ADRD). Our objective was to compare care experiences for MA beneficiaries with and without ADRD.

METHODS

We examined MA beneficiaries who completed the Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) and used inpatient, nursing home, or home health services in the past 3 years. We classified beneficiaries with ADRD using the presence of diagnosis codes in hospitals, nursing homes, and home health records. Our key measures included overall ratings of care and health plan, and indices of receiving timely care, care coordination, receiving needed care, and customer service. We compared differences between beneficiaries with and without ADRD using regression analysis adjusting for demographic, health, and plan characteristics, and stratifying by proxy response status.

RESULTS

Among beneficiaries sampled by CAHPS, 22.2% with ADRD completed the survey compared to 38.5% without ADRD. Among proxy responses, beneficiaries with ADRD were 4.2 (95% CI: 0.1-8.4) percentage points less likely to report a high score for receiving needed care, and 3.5 percentage points (95% CI: 0.2-6.9) less likely to report a high score for customer service. Among non-proxy responses, those with ADRD were 9.0 (95% CI: 5.5-12.5) percentage points less likely to report a high score for needed care, and 8.5 (95% CI: 5.4-11.5) percentage points less likely to report a high score for customer service.

CONCLUSIONS

ADRD respondents to the CAHPS were more likely to be excluded from CAHPS performance measures because they did not meet eligibility requirements and rates of non-response were higher. Among responders with or without a proxy, MA enrollees with an ADRD diagnosis reported worse care experiences in receiving needed care and in customer service than those without an ADRD diagnosis.

Repeatable enhancement of healthcare data with social determinants of health

Background

Social and behavioral aspects of our lives significantly impact our health, yet minimal social determinants of health (SDOH) data elements are collected in the healthcare system.

Methods

In this proof-of-concept study we developed a repeatable SDOH enrichment and integration process to incorporate dynamically evolving SDOH domain concepts from consumers into clinical data. This process included SDOH mapping, linking compiled consumer data to patient records in Electronic Health Records, data quality analysis and preprocessing, and storage.

Results

Consumer compilers data coverage ranged from ~90 to ~54% and the percentage match rate between compilers was between ~21 and 64%. Our preliminary analysis showed that apart from demographic factors, several SDOH factors like home-ownership, marital-status, presence of children, number of members per household, economic stability and education were significantly different between the COVID-19 positive and negative patient groups while estimated family-income and home market-value were not.

Conclusion

Our preliminary analysis shows commercial consumer data can be a viable source of SDOH factor at an individual-level for clinical data thus providing a path for clinicians to improve patient treatment and care.

Cancer Survivorship and Supportive Care Economics Research: Current Challenges and Next Steps

BACKGROUND

Rapid growth in the number of cancer survivors raises numerous questions about health and economic outcomes among survivors along with their families, caregivers, and employers. Health economics theory and methods can contribute to many open questions to improve survivorship.

METHODS

In this paper, we review key areas where more research is needed and describe strategies for improving data infrastructure, research funding, and capacity building to strengthen survivorship health economics research.

CONCLUSIONS

Health economics has broadened an understanding of key supply- and demand-side factors that promote cancer survivorship. To ensure necessary research in survivorship health economics moving forward, we recommend dedicated funding, inclusion of health economics outcomes in primary data collection, and investments in secondary data sets.

Exploring the predictors of financial impairment in Huntington's disease using the Enroll-HD dataset

OBJECTIVES

Huntington's disease (HD) is a neurodegenerative disease in which cognitive and behavioural symptoms impair the performance of instrumental activities of daily living, including the handling of finances. We sought to determine the prevalence of financial dysfunction in HD, and the demographic and clinical predictors of such impairments.

METHODS

We analysed longitudinal data for pre-manifest gene carriers and HD patients from the Enroll-HD dataset. Financial dysfunction was determined by finance-related items in the Total Functional Capacity (TFC) and Functional Assessment (FA) scales. A binary logistical regression model was used to investigate the predictive value of demographic and clinical factors for the development of financial dysfunction.

RESULTS

Financial impairment was found to be common in HD gene carriers, and over half required financial assistance within 5 years from diagnosis. Cognitive impairment, apathy, unemployment and disease severity predicted financial dysfunction in manifest patients. For pre-manifest patients, the predictors were proximity to disease onset and depression.

CONCLUSIONS

Loss of financial autonomy is common in HD, and cognitive and psychiatric factors are important in its development. Clinicians must be vigilant to identify patients that may be vulnerable to financial exploitation.

Self-awareness for financial decision making abilities is linked to right temporal cortical thickness in older adults

Everyday financial decision making and the awareness of the integrity of one's financial decision making abilities (or financial awareness) are both critical to study in older adults as they can help identify those at risk for making suboptimal financial decisions and prevent financial loss. In the current study, we examined the cognitive and cortical thickness correlates of financial decision making and financial awareness in 59 community-dwelling participants co-enrolled in a larger study (mean age=68.35 years (SD=5.5), mean education=15.91 (SD=2.36), 61% = women, 67% = White, 30% = Black participants). Data from standardized measures of financial decision making and cognition was investigated along with FreeSurfer (v. 5.3) derived thickness regions. Based on metacognitive frameworks, financial awareness was measured along with a well-validated measure of memory awareness. Results revealed that numeracy, executive functioning and vocabulary were associated with financial decision making, whereas in analysis adjusted for financial decision making, memory awareness relative to cognition was most strongly linked to financial awareness. No significant associations between thickness and financial decision making were found. However, both financial and memory awareness were associated with the same right-hemisphere temporal thickness regions underscoring the idea of a common substrate of awareness. Interestingly, our findings converge with the emerging work on financial exploitation in which the right sided temporal regions have been found to play a prominent role. Incorporating the contributing role of self-awareness in various models of financial exploitation will be an important consideration for future studies.

The WALLET Study: Examining early memory loss and personal finance

Background and Objectives

This feasibility study tests a new approach for assessing personal finance in older persons with early memory loss. The project examines 2 primary outcomes that gauge the financial viability and well-being of older adults: wealth loss and financial exploitation. The overall objective is to determine the association of financial literacy and management, financial decision-making, and cognition with wealth loss and financial exploitation.

Research Design and Methods

This cross-sectional study recruited 46 participants who were 60 years of age or older. Participants were classified as having mild cognitive impairment, perceived cognitive impairment, or no cognitive impairment. The study coordinator arranged with each participant to obtain copies of their main checking account statements for 12 consecutive months within the previous 2 years and, if appropriate, credit card statements. All statements were de-identified and assigned a random ID number. Participants then completed 2 telephone interviews.

Results

The average participant age was 72 years (standard deviation [SD] = 7.7); 84% were female, 39% White, and 35% currently married. Average education was 16.2 years (SD = 2.4); mean yearly household income was almost $42,000 (SD = 25,752); and monthly social security payments averaged $1,446 (SD = 1,244). Our results indicate that the methods used to analyze checking account statements, followed by telephone interviews to verify identified trends, were useful in developing a financial behavior index to measure wealth loss.

Discussion and Implications

We demonstrate an alternative method for assessing personal finance using person-centered principles, which we believe are critical in the presence of diminished or impaired cognition. Our findings offer an innovative method for assessing the risk for wealth loss and financial exploitation.

Molecular Insights into Therapeutic Potentials of Hybrid Compounds Targeting Alzheimer's Disease

Alzheimer's disease (AD) is one of the most complex progressive neurological disorders involving degeneration of neuronal connections in brain cells leading to cell death. AD is predominantly detected among elder people (> 65 years), mostly diagnosed with the symptoms of memory loss and cognitive dysfunctions. The multifarious pathogenesis of AD comprises the accumulation of pathogenic proteins, decreased neurotransmission, oxidative stress, and neuroinflammation. The conventional therapeutic approaches are limited to symptomatic benefits and are ineffective against disease progression. In recent years, researchers have shown immense interest in the designing and fabrication of various novel therapeutics comprised of naturally isolated hybrid molecules. Hybrid therapeutic compounds are developed from the combination of pharmacophores isolated from bioactive moieties which specifically target and block various AD-associated pathogenic pathways. The method of designing hybrid molecules has numerous advantages over conventional multitarget drug development methods. In comparison to in silico high throughput screening, hybrid molecules generate quicker results and are also less expensive than fragment-based drug development. Designing hybrid-multitargeted therapeutic compounds is thus a prospective approach in developing an effective treatment for AD. Nevertheless, several issues must be addressed, and additional researches should be conducted to develop hybrid therapeutic compounds for clinical usage while keeping other off-target adverse effects in mind. In this review, we have summarized the recent progress on synthesis of hybrid compounds, their molecular mechanism, and therapeutic potential in AD. Using synoptic tables, figures, and schemes, the review presents therapeutic promise and potential for the development of many disease-modifying hybrids into next-generation medicines for AD.

Financial decision-making and self-awareness for financial decision-making is associated with white matter integrity in older adults

Financial decision-making (FDM) and awareness of the integrity of one's FDM abilities (or financial awareness) are both critical for preventing financial mistakes. We examined the white matter correlates of these constructs and hypothesized that the tracts connecting the temporal-frontal regions would be most strongly correlated with both FDM and financial awareness. Overall, 49 healthy older adults were included in the FDM analysis and 44 in the financial awareness analyses. The Objective Financial Competency Assessment Inventory was used to measure FDM. Financial awareness was measured by integrating metacognitive ratings into this inventory and was calculated as the degree of overconfidence or underconfidence. Diffusion tensor imaging data were processed with Tracts Constrained by Underlying Anatomy distributed as part of the FreeSurfer analytic suite, which produced average measures of fractional anisotropy and mean diffusivity in 18 white matter tracts along with the overall tract average. As expected, FDM showed the strongest negative associations with average mean diffusivity measure of the superior longitudinal fasciculus -temporal (SLFT; r = -.360, p = .011) and -parietal (r = -.351, p = .014) tracts. After adjusting for FDM, only the association between financial awareness and average mean diffusivity measure of the right SLFT (r = .310, p = .046) was significant. Overlapping white matter tracts were involved in both FDM and financial awareness. More importantly, these preliminary findings reinforce emerging literature on a unique role of right hemisphere temporal connections in supporting financial awareness.

Risk factors of falls in elderly patients with visual impairment

OBJECTIVE

To examine the risk factors for falls in elderly patients with visual impairment (VI) and assess the predictive performance of these factors.

METHODS

Between January 2019 and March 2021, a total of 251 elderly patients aged 65-92 years with VI were enrolled and then prospectively followed up for 12 months to evaluate outcomes of accidental falls via telephone interviews. Information of demographics and lifestyle, gait and balance deficits, and ophthalmic and systemic conditions were collected during baseline visits. Forward stepwise multivariable logistic regression analysis was performed to identify independent risk factors of falls in elderly patients with VI, and a derived nomogram was constructed.

RESULTS

A total of 143 falls were reported in 251 elderly patients during follow-up, with an incidence of 56.97%. The risk factors for falls in elderly patients with VI identified by multivariable logistic regression were women [odds ratio (OR), 95% confidence interval (CI): 2.71, 1.40-5.27], smoking (3.57, 1.34-9.48), outdoor activities/3 months (1.31, 1.08-1.59), waking up frequently during the night (2.08, 1.15-3.79), disorders of balance and gait (2.60, 1.29-5.24), glaucoma (3.12, 1.15-8.44), other retinal degenerations (3.31, 1.16-9.43) and best-corrected visual acuity (BCVA) of the better eye (1.79, 1.10-2.91). A nomogram was developed based on the abovementioned multivariate analysis results. The area under receiver operating characteristic curve of the predictive model was 0.779.

CONCLUSIONS

Gender, smoking, outdoor activities, waking up at night, disorders of balance and gait, glaucoma, other retinal degeneration and BCVA of the better eye were independent risk factors for falls in elderly patients with VI. The predictive model and derived nomogram achieved a satisfying prediction of fall risk in these individuals.

Shared genetic architecture between the two neurodegenerative diseases: Alzheimer's disease and glaucoma

BACKGROUND

Considered as the representatives of neurodegenerative diseases, Alzheimer's disease (AD) and glaucoma are complex progressive neuropathies affected by both genetic and environmental risk factors and cause irreversible damages. Current research indicates that there are common features between AD and glaucoma in terms of epidemiology and pathophysiology. However, the understandings and explanations of their comorbidity and potential genetic overlaps are still limited and insufficient.

METHOD

Genetic pleiotropy analysis was performed using large genome-wide association studies summary statistics of AD and glaucoma, with an independent cohort of glaucoma for replication. Conditional and conjunctional false discovery rate methods were applied to identify the shared loci. Biological function and network analysis, as well as the expression level analysis were performed to investigate the significance of the shared genes.

RESULTS

A significant positive genetic correlation between AD and glaucoma was identified, indicating that there were significant polygenetic overlaps. Forty-nine shared loci were identified and mapped to 11 shared protein-coding genes. Functional genomic analyses of the shared genes indicate their modulation of critical physiological processes in human cells, including those occurring in the mitochondria, nucleus, and cellular membranes. Most of the shared genes indicated a potential modulation of metabolic processes in human cells and tissues. Furthermore, human protein-protein interaction network analyses revealed that some of the shared genes, especially MTCH2, NDUFS3, and PTPMT1, as well as SPI1 and MYBPC3, may function concordantly. The modulation of their expressions may be related to metabolic dysfunction and pathogenic processes.

CONCLUSION

Our study identified a shared genetic architecture between AD and glaucoma, which may explain their shared features in epidemiology and pathophysiology. The potential involvement of these shared genes in molecular and cellular processes reflects the "inter-organ crosstalk" between AD and glaucoma. These results may serve as a genetic basis for the development of innovative and effective therapeutics for AD, glaucoma, and other neurodegenerative diseases.

The Psychiatric Misdiagnosis of Behavioral Variant Frontotemporal Dementia in a Colombian Sample

Objective: To describe the demographic characteristics, initial psychiatric diagnoses, and the time to reach a diagnosis of probable behavioral variant frontotemporal dementia (bvFTD) in a public psychiatric hospital in Cali, Colombia. Methods: We retrospectively reviewed the medical records of 28 patients who were diagnosed with probable bvFTD based on a multidisciplinary evaluation that included a structural MRI, neuropsychological testing, functional assessment, and neurological exam. Prior to this evaluation, all patients were evaluated by a psychiatrist as part of their initial consultation at the hospital. The initial consultation included the Neuropsychiatric Inventory and diagnoses based on the DSM-V. Demographics, clinical features, and initial psychiatric misdiagnoses were extracted from clinical records and summarized in the full sample and by gender. Results: The study sample had a mean education of 10.0 years (SD = 4.9) and 68.0% were female. In the full sample, 28.6% were initially diagnosed with dementia, and 71.4% with a psychiatric disorder. The psychiatric diagnosis at initial consultation differed by gender. Women were most likely to be diagnosed with depression (26.3%) or bipolar disorder (26.3%), while the men were most likely to be diagnosed with anxiety (33.3%) or a psychotic disorder (22.2%). Psychotic symptoms were common (delusions, 60.7% and hallucinations, 39.3%), and the pattern of neuropsychiatric symptoms did not differ by gender. Conclusions: This is one of few case series of bvFTD in a Colombian population, where bvFTD is a recognizable and prevalent disorder. In this psychiatric hospital, the majority of patients with bvFTD were initially diagnosed with a primary psychiatric condition. There was a gender difference in psychiatric diagnosis, but not in neuropsychiatric symptoms. In this sample, the rate of psychiatric misdiagnosis, as well as the psychotic symptoms, were higher compared to rates described in other countries. These results highlight the need for interventions to improve bvFTD diagnosis in under-represented populations.

Cognitive Assessment Tools Recommended in Geriatric Oncology Guidelines: A Rapid Review

Cognitive assessment is a cornerstone of geriatric care. Cognitive impairment has the potential to significantly impact multiple phases of a person's cancer care experience. Accurately identifying this vulnerability is a challenge for many cancer care clinicians, thus the use of validated cognitive assessment tools are recommended. As international cancer guidelines for older adults recommend Geriatric Assessment (GA) which includes an evaluation of cognition, clinicians need to be familiar with the overall interpretation of the commonly used cognitive assessment tools. This rapid review investigated the cognitive assessment tools that were most frequently recommended by Geriatric Oncology guidelines: Blessed Orientation-Memory-Concentration test (BOMC), Clock Drawing Test (CDT), Mini-Cog, Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and Short Portable Mental Status Questionnaire (SPMSQ). A detailed appraisal of the strengths and limitations of each tool was conducted, with a focus on practical aspects of implementing cognitive assessment tools into real-world clinical settings. Finally, recommendations on choosing an assessment tool and the additional considerations beyond screening are discussed.

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.

Examining the Validity of the Financial Exploitation Vulnerability Scale

Objectives: Objectives: Lichtenberg, Campbell, Hall, and Gross used a contextual framework for financial decision-making to create and provide evidence for a new scale to assess risk for financial exploitation, the Financial Exploitation Vulnerability Scale (FEVS). This study examined the criterion validity of self-reported memory complaints and living alone on FEVS risk scores.Methods: Participants were the first 258 individuals reporting as 60 years or older and who completed the FEVS on the https://olderadultnestegg.com website between December 2020 and February 2021. Correlations, multiple regression, analysis of variance, and chi-square analyses were conducted to compare groups based on risk scores.Results: FEVS risk scores were significantly correlated with years of education, self-reported memory complaints, and living alone; 18% of unique variance was accounted for by these measures in a regression analysis. The ANOVA indicated that while there was an interaction effect for memory complaints by living alone, the majority of variance accounted for was attributed to the self-reported memory complaints measure. Conclusions: Older adults with memory complaints are in need of perceived financial vulnerability assessment.Clinical Implications: The Financial Exploitation Vulnerability Scale is a valuable self-report tool that clinical gerontologists can use in their intake assessments and follow-ups.

Prevalence of Memory-Related Diagnoses Among U.S. Older Adults With Early Symptoms of Cognitive Impairment

BACKGROUND

Early diagnosis of cognitive impairment may confer important advantages. Yet the prevalence of memory-related diagnoses among older adults with early symptoms of cognitive impairment is unknown.

METHODS

A retrospective, longitudinal cohort design using 2000-2014 Health and Retirement Survey-Medicare linked data. We leveraged within-individual variation to examine the relationship between incident cognitive impairment and receipt of diagnosis among 1225 individuals aged 66 or older. Receipt of a memory-related diagnosis was determined by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Incident cognitive impairment was defined as the first assessment wherein the participant's modified Telephone Interview for Cognitive Status score was less than 12.

RESULTS

The unadjusted prevalence of memory-related diagnosis at cognitive impairment was 12.0%. Incident cognitive impairment was associated with a 7.3% (95% confidence interval [CI], 5.6% to 9.0%; p < .001) higher adjusted probability of any memory-related diagnosis overall, yielding 9.8% adjusted prevalence of diagnosis. The increase in likelihood of diagnosis associated with cognitive decline was significantly higher among non-Hispanic Whites than non-Hispanic Blacks (8.2% vs -0.7%), and among those with at least a college degree than those with a high school diploma or less (17.4% vs 6.8% vs 1.6%). Those who were younger, had below-median wealth, or without a partner had lower probability of diagnosis than their counterparts.

CONCLUSIONS

We found overall low prevalence of early diagnosis, or high rate of underdiagnosis, among older adults showing symptoms of cognitive impairment, especially among non-Whites and socioeconomically disadvantaged subgroups. Our findings call for targeted interventions to improve the rate of early diagnosis, especially among vulnerable populations.

Single and Combined Neuroimaging Techniques for Alzheimer's Disease Detection

Alzheimer's disease (AD) consists of the gradual process of decreasing volume and quality of neuron connection in the brain, which consists of gradual synaptic integrity and loss of cognitive functions. In recent years, there has been significant attention in AD classification and early detection with machine learning algorithms. There are different neuroimaging techniques for capturing data and using it for the classification task. Input data as images will help machine learning models to detect different biomarkers for AD classification. This marker has a more critical role for AD detection than other diseases because beta-amyloid can extract complex structures with some metal ions. Most researchers have focused on using 3D and 4D convolutional neural networks for AD classification due to reasonable amounts of data. Also, combination neuroimaging techniques like functional magnetic resonance imaging and positron emission tomography for AD detection have recently gathered much attention. However, gathering a combination of data can be expensive, complex, and tedious. For time consumption reasons, most patients prefer to throw one of the neuroimaging techniques. So, in this review article, we have surveyed different research studies with various neuroimaging techniques and ML methods to see the effect of using combined data as input. The result has shown that the use of the combination method would increase the accuracy of AD detection. Also, according to the sensitivity metrics from different machine learning methods, MRI and fMRI showed promising results.

Impact of dementia: Health disparities, population trends, care interventions, and economic costs

INTRODUCTION

The dementia experience is not a monolithic phenomenon-and while core elements of dementia are considered universal-people living with dementia experience the disorder differently. Understanding the patterning of Alzheimer's disease and related dementias (ADRD) in the population with regards to incidence, risk factors, impacts on dementia care, and economic costs associated with ADRD can provide clues to target risk and protective factors for all populations as well as addressing health disparities.

METHODS

We discuss information presented at the 2020 National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers, Theme 1: Impact of Dementia. In this article, we describe select population trends, care interventions, and economic impacts, health disparities and implications for future research from the perspective of our diverse panel comprised of academic stakeholders, and persons living with dementia, and care partners.

RESULTS

Dementia incidence is decreasing yet the advances in population health are uneven. Studies examining the educational, geographic and race/ethnic distribution of ADRD have identified clear disparities. Disparities in health and healthcare may be amplified by significant gaps in the evidence base for pharmacological and non-pharmacological interventions. The economic costs for persons living with dementia and the value of family care partners' time are high, and may persist into future generations.

CONCLUSIONS

Significant research gaps remain. Ensuring that ADRD healthcare services and long-term care services and supports are accessible, affordable, and effective for all segments of our population is essential for health equity. Policy-level interventions are in short supply to redress broad unmet needs and systemic sources of disparities. Whole of society challenges demand research producing whole of society solutions. The urgency, complexity, and scale merit a "whole of government" approach involving collaboration across numerous federal agencies.