Physician outpatient contacts and hospitalizations among cognitively impaired elderly

Health Care Access and Cognitive Function in Older Adults: A Cross-Lagged Panel Longitudinal Analysis

Objective: The current longitudinal study examined how (1) cognitive measures, including episodic memory, executive function, and global cognition, predict later healthcare access and how (2) healthcare access predicts later cognition. Methods: Drawing a sample (n = 9920) from the Health and Retirement Study dataset, we created a cross-lagged panel model to examine the longitudinal association between cognitive measures and healthcare access from 2012 to 2018. Results: Results revealed that cognitive measures significantly predict later healthcare access, with effects increasing across waves. However, within sub-domains, memory was more predictive of later healthcare access over time compared to executive function. Discussions: Our study suggested an increased link between cognition and healthcare access during aging. Even outside of the context of AD, there are likely both policy-based and practical implications to ensure those experiencing cognitive decline continue to maintain access to care.

Dementia and Related Comorbidity: Analysis of 2 Years of Admissions to Italian Hospitals

BACKGROUND

The aim of the present study was to examine the prevalence of dementia, related comorbidities, and mortality rates in hospitalized elderly patients in Italy.

METHODS

Data were obtained from the Italian Ministry of Health and included all discharge records from Italian hospitals concerning subjects aged 65 years or above admitted to acute Internal Medicine during 2 years (n=3,695,278 admissions). Discharge diagnoses were re-classified into 24 clusters, each including homogeneous diseases by the ICD-9-CM code classification. Dementia was identified by the presence of ICD-9-CM codes 290, 294, or 331 series.

RESULTS

Patients with dementia represented 7.5% of the sample; compared with those without dementia, they were older and more often female, had a greater length of hospital stay and higher mortality rate. Besides delirium [odds ratio (OR): 54.20], enthesopaties (OR: 2.19), diseases of fluids and electrolytes (OR:1.96), diseases of arteries (OR: 1.69), skin diseases (OR: 1.64), and pneumonia and pleurisy (OR: 1.53) were the diseases more strongly associated with the diagnosis of dementia, independent of other clusters, age, sex, and length of stay.

CONCLUSIONS

Some comorbidities are specifically associated with the diagnosis of dementia among hospitalized elderly patients. Overall, these comorbidities describe the typical clinical profile of the patient with advanced dementia and could be treated in the context of the primary care, since they do not require specific skills belonging to hospital settings.

Dementia and in-hospital mortality: retrospective analysis of a nationwide administrative database of elderly subjects in Italy

AIMS

 To evaluate the relationship between comorbidity and in-hospital mortality in elderly patients affected by dementia.

METHODS

Data were obtained from the Italian Ministry of Health and included all discharge records from Italian hospitals concerning subjects aged ≥ 65 years admitted to acute Internal Medicine or Geriatrics wards between January 2015 and December 2016 (3.695.278 admissions). The variables analyzed included age, sex, and in-hospital death. Twenty-five homogeneous clusters of diseases were identified in discharge codes according to the ICD-9-CM classification.

RESULTS

Patients with dementia represented 7.5% of the sample (n. 278.149); they were older, more often males (51.9%), and had a higher in-hospital mortality (24.3%) compared to patients without dementia (9.7%). Dementia per se doubled the odds of death (OR 1.98; 95% CI 1.95-2.00), independent of age, sex, and comorbidities. Seven clusters of disease (pneumonia, heart failure, kidneys disease, cancer, infectious diseases, diseases of fluids/electrolytes and general symptoms) were associated with increased in-hospital mortality, independent of the presence/absence of dementia. Among patients with dementia, heart failure, pneumonia and kidney disease on their own substantially doubled/tripled mortality risk. The risk increased from 10.1% (none of selected conditions), up to 28.9% when only one of selected comorbidities was present, rising to 52.3% (OR: 9.34; p < 0.001) when two or more comorbidities were simultaneously diagnosed, besides general symptoms.

CONCLUSIONS

Our study confirmed an important increase of in-hospital mortality in older subjects with dementia. Despite a different comorbidity, the conditions associated with in-hospital mortality were substantially the same in patients with or without dementia. Heart failure, pneumonia, and kidney disease identified a high risk of in-hospital mortality among subjects with dementia.

Adjunctive Therapy to Manage Neuropsychiatric Symptoms in Moderate and Severe Dementia: Randomized Clinical Trial Using an Outpatient Version of Tailored Activity Program

BACKGROUND

Neuropsychiatric symptoms (NPS) such as aggression, apathy, agitation, and wandering may occur in up to 90%of dementia cases. International guidelines have suggested that non-pharmacological interventions are as effective as pharmacological treatments, however without the side effects and risks of medications. An occupational therapy method, called Tailored Activity Program (TAP), was developed with the objective to treat NPS in the elderly with dementia and has been shown to be effective.

OBJECTIVE

Evaluate the efficacy of the TAP method (outpatient version) in the treatment of NPS in individuals with dementia and in the burden reduction of their caregivers.

METHODS

This is a randomized, double-blind, controlled clinical trial for the treatment of NPS in dementia. Outcome measures consisted of assessing the NPS of individuals with dementia, through the Neuropsychiatric Inventory-Clinician rating scale (NPI-C), and assessing the burden on their caregivers, using the Zarit Scale. All the participants were evaluated pre-and post-intervention.

RESULTS

54 individuals with dementia and caregivers were allocated to the experimental (n = 28) and control (n = 26) groups. There was improvement of the following NPS in the experimental group: delusions, agitation, aggressiveness, depression, anxiety, euphoria, apathy, disinhibition, irritability, motor disturbance, and aberrant vocalization. No improvement was observed in hallucinations, sleep disturbances, and appetite disorders. The TAP method for outpatient settings was also clinically effective in reducing burden between caregivers of the experimental group.

CONCLUSION

The use of personalized prescribed activities, coupled with the caregiver training, may be a clinically effective approach to reduce NPS and caregiver burden of individuals with dementia.

Which Occupation is Highly Associated with Cognitive Impairment? A Gender-Specific Longitudinal Study of Paid and Unpaid Occupations in South Korea

Background: To examine the associations between paid and unpaid occupations and the risk of cognitive impairment with respect to gender in a middle-aged population using the dataset of a nationally representative longitudinal survey. Methods: Overall, 24,925 observations of 5865 participants aged 45–64 years were sampled from the seven waves of the Korean Longitudinal Study of Ageing (2006–2018). A dichotomous outcome variable was derived based on the Korean version of the Mini-Mental State Examination scores, and occupations were grouped into 12 categories, including three unpaid ones. Sociodemographics, lifestyle, and medical conditions were included as covariates in the mixed logistic regression models. Adjusted odds ratios and predicted probabilities of cognitive impairment were estimated. Results: In the longitudinal models with all-studied covariates, the risk of cognitive impairment was similar between genders but differed across occupation categories for each gender. Moreover, the association between occupation and cognitive impairment varied between genders. Regarding the predicted probability, in men, the retired category exhibited the highest risk of cognitive impairment. However, in women, the highest risk was related to the homemakers category, with the risk being more than five times higher than those in the professionals and related workers category. Conclusions: Public health policies to reduce the risk of cognitive impairment in the middle-aged population need to be designed and implemented with respect to both gender and occupation.

Mortality in people with dementia, delirium, and unspecified cognitive impairment in the general hospital: prospective cohort study of 6,724 patients with 2 years follow-up

Purpose

Cognitive impairment is common in older people admitted to hospital, but the outcomes are generally poorly understood, and previous research has shown inconsistent associations with mortality depending on the type of cognitive impairment examined and duration of follow-up. This study examines mortality in older people with any cognitive impairment during acute hospital admission.

Patients and methods

Prospective cohort of 6,724 people aged ≥65 years with a structured cognitive assessment on acute admission were included in this study. Cognitive spectrum disorder (CSD) was defined as delirium alone, known dementia alone, delirium superimposed on known dementia, or unspecified cognitive impairment. Mortality associated with different types of CSD was examined using a non-proportional hazards model with 2-year follow-up.

Results

On admission, 35.4% of patients had CSD, of which 52.6% died within 2 years. After adjustment for demographics and comorbidity, delirium alone was associated with increased mortality in the 6 months post-admission (HR =1.45, 95% CI 1.28-1.65) and again after 1 year (HR =1.44, 95% CI 1.17-1.77). Patients with known dementia (alone or with superimposed delirium) had increased mortality only after 3 months from admission (HR =1.85, 95% CI 1.56-2.18 and HR =1.80, 95% CI 1.52-2.14) compared with patients with unspecified cognitive impairment after 6 months (HR =1.55, 95% CI 1.21-1.99). Similar but partially attenuated associations were seen after adjustment for functional ability.

Conclusion

Mortality post-admission is high in older people with CSD. Immediate risk is highest in those with delirium, while dementia or unspecified cognitive impairment is associated with medium- to long-term risk. These findings suggest that individuals without dementia who develop delirium are more seriously ill (have required a larger acute insult in order to precipitate delirium) than those with pre-existing brain pathology (dementia). Further research to explain the mortality patterns observed is required in order to translate the findings into clinical care.

Emergency Department Use by Community-Dwelling Individuals With Dementia in the United States: An Integrative Review

As part of the National Plan to Address Alzheimer's Disease, reducing potentially avoidable emergency department (ED) use by individuals with dementia has been identified as a component of enhancing the quality and efficiency of care for this population. To help inform the development of interventions to achieve this goal, an integrative review was conducted to: (a) compare rates and reasons for ED visits by community-dwelling individuals with and without dementia, considering also the effect of dementia subtype and severity; and (b) identify other risk factors for increased ED use among community-dwelling individuals with dementia. Nineteen articles met inclusion criteria. Individuals with dementia had higher rates of ED visits compared to those without dementia, although differences were attenuated in the last year of life. Increased symptoms and disability were associated with increased rates of ED visits, whereas resources that enabled effective management of increased need decreased rates. Gerontological nurses across settings are on the frontlines of preventing potentially avoidable ED visits by community-dwelling individuals with dementia through patient and family education and leadership in the development of new models of care. [Journal of Gerontological Nursing, 44(3), 23-30.].

Epidemiology and outcomes of people with dementia, delirium, and unspecified cognitive impairment in the general hospital: prospective cohort study of 10,014 admissions

BACKGROUND

Cognitive impairment of various kinds is common in older people admitted to hospital, but previous research has usually focused on single conditions in highly-selected groups and has rarely examined associations with outcomes. This study examined prevalence and outcomes of cognitive impairment in a large unselected cohort of people aged 65+ with an emergency medical admission.

METHODS

Between January 1, 2012, and June 30, 2013, admissions to a single general hospital acute medical unit aged 65+ underwent a structured specialist nurse assessment (n = 10,014). We defined 'cognitive spectrum disorder' (CSD) as any combination of delirium, known dementia, or Abbreviated Mental Test (AMT) score < 8/10. Routine data for length of stay (LOS), mortality, and readmission were linked to examine associations with outcomes.

RESULTS

A CSD was present in 38.5% of all patients admitted aged over 65, and in more than half of those aged over 85. Overall, 16.7% of older people admitted had delirium alone, 7.9% delirium superimposed on known dementia, 9.4% known dementia alone, and 4.5% unspecified cognitive impairment (AMT score < 8/10, no delirium, no known dementia). Of those with known dementia, 45.8% had delirium superimposed. Outcomes were worse in those with CSD compared to those without - LOS 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year death or readmission 62.4% vs. 51.5% (all P < 0.01). There was relatively little difference by CSD type, although people with delirium superimposed on dementia had the longest LOS, and people with dementia the worst mortality at 1 year.

CONCLUSIONS

CSD is common in older inpatients and associated with considerably worse outcomes, with little variation between different types of CSD. Healthcare systems should systematically identify and develop care pathways for older people with CSD admitted as medical emergencies, and avoid only focusing on condition-specific pathways such as those for dementia or delirium alone.

Severity of memory impairment in the elderly: Association with health care resource use and functional limitations in the United States

INTRODUCTION

Dementia is a prevalent condition in older adults associated with decline in cognitive and functional abilities and substantial burden. This study assessed the prevalence and impact of subjective memory impairment in the United States.

METHODS

The 2011 to 2014 National Health and Nutrition Examination Survey, a population-based, nationally representative survey, was analyzed. Data included medical examinations, self-reported cognitive and functional limitations, and health care utilization over 1 year. Participants were aged ≥65 years and completed both interview and medical examination components. Descriptive analyses of patient characteristics were performed, and complex survey regression models were used to test associations.

RESULTS

Of 2431 survey participants included, 53.1% had no memory impairment, 40.1% had early-stage memory impairment, and 6.6% had late-stage memory impairment. In adjusted analyses, late-stage versus no impairment was associated with more functional limitations (odds ratio [OR] = 7.26, P < .001), greater health care utilization (OR = 2.46, P < .001), and higher likelihood of seeing a mental health specialist (OR = 3.06, P = .001).

DISCUSSION

Consistent with previous research, individuals with late-stage memory impairment had significantly greater functional limitations and higher health care utilization versus individuals with early-stage or no memory impairment.

Family caregivers’ reports of hospitalizations and emergency department visits in community-dwelling individuals with dementia

Individuals with dementia in the United States have higher rates of hospitalizations and emergency department visits compared to those without. This descriptive study examined the frequency of hospitalizations and emergency department visits among community-dwelling individuals with dementia, reasons for hospitalizations and emergency department visits, and caregivers’ actions to prevent these events. Family caregivers ( n = 63) from education/support groups offered through Alzheimer’s Association chapters in western Ohio completed a survey. Twenty-two percent of caregivers reported that their care recipient stayed overnight in the hospital and 30% reported that their care recipient visited the emergency department at least once in the past three months. The most frequent reasons for hospitalization and emergency department visits, such as urinary tract infections and fall-related injuries, were potentially avoidable. Caregivers reported giving medications, seeking healthcare services, and obtaining home care services, as the most frequently used preventive actions. Family caregivers of individuals with dementia should be provided substantive education about preventable hospitalizations and emergency department visits.

Direct medical costs and source of cost differences across the spectrum of cognitive decline: a population-based study

BACKGROUND

Objective cost estimates and source of cost differences are needed across the spectrum of cognition, including cognitively normal (CN), mild cognitive impairment (MCI), newly discovered dementia, and prevalent dementia.

METHODS

Subjects were a subset of the Mayo Clinic Study of Aging stratified-random sampling of Olmsted County, MN, residents aged 70 to 89 years. A neurologist reviewed provider-linked medical records to identify prevalent dementia (review date = index). Remaining subjects were invited to participate in prospective clinical/neuropsychological assessments; participants were categorized as CN, MCI, or newly discovered dementia (assessment date = index). Costs for medical services/procedures 1-year pre-index (excluding indirect and long-term care costs) were estimated using line-item provider-linked administrative data. We estimated contributions of care-delivery site and comorbid conditions (including and excluding neuropsychiatric diagnoses) to between-category cost differences.

RESULTS

Annual mean medical costs for CN, MCI, newly discovered dementia, and prevalent dementia were $6042, $6784, $9431, $11,678, respectively. Hospital inpatient costs contributed 70% of total costs for prevalent dementia and accounted for differences between CN and both prevalent and newly discovered dementia. Ambulatory costs accounted for differences between CN and MCI. Age-, sex-, education-adjusted differences reached significance for CN versus newly discovered and prevalent dementia and for MCI versus prevalent dementia. After considering all comorbid diagnoses, between-category differences were reduced (e.g., prevalent dementia minus MCI (from $4842 to $3575); newly discovered dementia minus CN (from $3578 to $711)). Following the exclusion of neuropsychiatric diagnoses from comorbidity adjustment, between-category differences tended to revert to greater differences.

CONCLUSIONS

Cost estimates did not differ significantly between CN and MCI. Substantial differences between MCI and prevalent dementia reflected high inpatient costs for dementia and appear partly related to co-occurring mental disorders. Such comparisons can help inform models aimed at identifying where, when, and for which individuals proposed interventions might be cost-effective.

Assessment and management of behavioral and psychological symptoms of dementia

Behavioral and psychological symptoms of dementia include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of inappropriate behaviors. One or more of these symptoms will affect nearly all people with dementia over the course of their illness. These symptoms are among the most complex, stressful, and costly aspects of care, and they lead to a myriad of poor patient health outcomes, healthcare problems, and income loss for family care givers. The causes include neurobiologically related disease factors; unmet needs; care giver factors; environmental triggers; and interactions of individual, care giver, and environmental factors. The complexity of these symptoms means that there is no "one size fits all solution," and approaches tailored to the patient and the care giver are needed. Non-pharmacologic approaches should be used first line, although several exceptions are discussed. Non-pharmacologic approaches with the strongest evidence base involve family care giver interventions. Regarding pharmacologic treatments, antipsychotics have the strongest evidence base, although the risk to benefit ratio is a concern. An approach to integrating non-pharmacologic and pharmacologic treatments is described. Finally, the paradigm shift needed to fully institute tailored treatments for people and families dealing with these symptoms in the community is discussed.

Association of living alone and hospitalization among community-dwelling elders with and without dementia

BACKGROUND

Older persons account for the majority of hospitalizations in the United States.1 Identifying risk factors for hospitalization among elders, especially potentially preventable hospitalization, may suggest opportunities to improve primary care. Certain factors-for example, living alone-may increase the risk for hospitalization, and their effect may be greater among persons with dementia and the old-old (aged 85+).

OBJECTIVES

To determine the association of living alone and risk for hospitalization, and see if the observed effect is greater among persons with dementia or the old-old.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

2,636 participants in the Adult Changes in Thought (ACT) study, a longitudinal cohort study of dementia incidence. Participants were adults aged 65+ enrolled in an integrated health care system who completed biennial follow-up visits to assess for dementia and living situation.

MAIN MEASURES

Hospitalization for all causes and for ambulatory care sensitive conditions (ACSCs) were identified using automated data.

KEY RESULTS

At baseline, the mean age of participants was 75.5 years, 59 % were female and 36 % lived alone. Follow-up time averaged 8.4 years (SD 3.5), yielding 10,431 approximately 2-year periods for analysis. Living alone was positively associated with being aged 85+, female, and having lower reported social support and better physical function, and negatively associated with having dementia. In a regression model adjusted for age, sex, comorbidity burden, physical function and length of follow-up, living alone was not associated with all-cause (OR = 0.93; 95 % CI 0.84, 1.03) or ambulatory care sensitive condition (ACSC) hospitalization (OR = 0.88; 95 % CI 0.73, 1.07). Among participants aged 85+, living alone was associated with a lower risk for all-cause (OR = 0.76; 95 % CI 0.61, 0.94), but not ACSC hospitalization. Dementia did not modify any observed associations.

CONCLUSION

Living alone in later life did not increase hospitalization risk, and in this population may be a marker of healthy aging in the old-old.

Progress in diagnosis and management of Alzheimer's disease

Purpose

Knowledge of Alzheimer's disease (AD), timely recognition and good management should be the norm in all health and social care settings. This paper seeks to focus on developments in diagnosis and treatment.

Design/methodology/approach

Key research papers and policy documents published in the last few years are reviewed, with an emphasis on those most relevant to Wales.

Findings

The number of people with AD is predicted to steadily increase over the next 40 years. Recent policy developments have recognised the importance of better identification and management of dementia and have proposed memory clinics as the core of new services for early diagnosis and identification. Newer biomarkers of AD enable diagnosis to be made more reliably and at a stage before the patient is demented (prodromal AD). Latest guidance from the National Institute for Health and Clinical Excellence (NICE) now recommends that the use of anticholinesterase inhibitor drugs or memantine is considered in all patients with AD. There is active research into newer treatment approaches, notably the role of cognitive rehabilitation in early dementia and the use of potentially disease‐modifying drugs such as anti‐amyloid antibodies. Unfortunately, current research funding is inadequate and only a small minority of people with AD become involved with research.

Originality/value

The paper shows that, given the growing importance of AD, there is an urgent need to boost recruitment of people with dementia into research trials. There is also a need to address ethical considerations of diagnosing prodromal AD – this is important for both the person undergoing assessment and for society as a whole.

Discharge diagnosis and comorbidity profile in hospitalized older patients with dementia

OBJECTIVES

The aim of this study was to investigate the principal discharge diagnosis and related comorbidity in hospitalized older patients affected by dementia.

METHODS

Data from 51,838 consecutive computerized discharge records of the St. Anna University Hospital (Ferrara, Italy) were analyzed. Records included only subjects aged ≥60 years. Number of admissions, length of stay in hospital, primary and secondary discharge diagnosis (by ICD-9-CM code), number of procedures, and possible death were evaluated.

RESULTS

Demented patients represented 8.6% of the sample (4466 individuals) and were older and more likely to be female patients compared with controls (47,372 individuals); they were characterized by higher number of admissions to hospital, instrumental clinical investigations, secondary diagnoses, and mortality rate. Among the primary diagnoses, a higher prevalence of cerebrovascular disease, pneumonia, and hip fracture was observed in demented patients. Furthermore, pulmonary embolism, renal failure, septicemia, and urinary infections were frequently reported in demented patients, but not in controls. As regards secondary diagnoses, dementia was associated with an increased risk of delirium, muscular atrophy and immobilization, dehydration, cystitis, and pressure ulcers, whereas the risk for other conditions, including cancer, was reduced.

CONCLUSIONS

Among older patients, dementia was associated with higher rate of admissions to hospital and mortality. Discharge diagnoses were sensibly different according to the presence of dementia; in particular, a greater load and a different kind of comorbidity were observed in demented patients. On the whole, our data suggest that the adequate management of demented outpatients might help to reduce hospitalization.

Dementia as a determinant of social and health service use in the last two years of life 1996-2003

BACKGROUND

Dementia is one of the most common causes of death among old people in Finland and other countries with high life expectancies. Dementing illnesses are the most important disease group behind the need for long-term care and therefore place a considerable burden on the health and social care system. The aim of this study was to assess the effects of dementia and year of death (1998-2003) on health and social service use in the last two years of life among old people.

METHODS

The data were derived from multiple national registers in Finland and comprise all those who died in 1998, 2002 or 2003 and 40% of those who died in 1999-2001 at the age of 70 or over (n = 145 944). We studied the use of hospitals, long-term care and home care in the last two years of life. Statistics were performed using binary logistic regression analyses and negative binomial regression analyses, adjusting for age, gender and comorbidity.

RESULTS

The proportion of study participants with a dementia diagnosis was 23.5%. People with dementia diagnosis used long-term care more often (OR 9.30, 95% CI 8.60, 10.06) but hospital (OR 0.33, 95% CI 0.31, 0.35) and home care (OR 0.50, 95% CI 0.46, 0.54) less often than people without dementia. The likelihood of using university hospital and long-term care increased during the eight-year study period, while the number of days spent in university and general hospital among the users decreased. Differences in service use between people with and without dementia decreased during the study period.

CONCLUSIONS

Old people with dementia used long-term care to a much greater extent and hospital and home care to a lesser extent than those without dementia. This difference persisted even when controlling for age, gender and comorbidity. It is important that greater attention is paid to ensuring that old people with dementia have equitable access to care.

Undiagnosed illness and neuropsychiatric behaviors in community residing older adults with dementia

The aim of this retrospective analysis was to examine prevalence of undiagnosed acute illness and characteristics including neuropsychiatric symptoms associated with illness in community residing older adults with Alzheimer disease or related disorders. Subjects included 265 community residing older adults with dementia who participated in 1 of 2 interventions being tested in randomized clinical trials. Measures included a brief nursing assessment and laboratory evaluations including complete blood count, blood chemistry (Chem 7), and thyroid function tests of serum samples and culture and sensitivity tests of urine samples. Undiagnosed illness was identified according to currently published criteria. Neuropsychiatric behaviors were assessed using 21 behaviors derived from standard measures. Thirty-six percent (N=96) of patients had clinical findings indicative of undetected illness. Conditions most prevalent were bacteriuria (15%), followed by hyperglycemia (6%) and anemia (5%). The behavior most often demonstrated among those with detected illness was resisting or refusing care (66% vs. 47% for those without detected illness). Individuals with detected illness had significantly lower functional status scores [3.8 vs. 4.4, t(275)=7.01, P=0.01], lower cognitive status scores [10.5 vs. 14.4, t(275)=12.1, P<0.01], and were more likely to be prescribed psychotropic medications for behavior (41% vs. 26%, χ=3.67, P<0.05) than those without illness. Findings suggest that challenges of diagnosing acute illness with atypical presentation must be addressed to promote quality of care and the specialized needs for this vulnerable population.

2010 Alzheimer's disease facts and figures

Alzheimer's disease (AD) is the seventh leading cause of all deaths in the United States and is virtually tied with the sixth leading cause of death-diabetes. AD is the fifth leading cause of death in Americans aged 65 and older. Although other major causes of death have been on the decrease, deaths because of AD have been rising dramatically. Between 2000 and 2006, heart disease deaths decreased 11.1%, stroke deaths decreased 18.2%, and prostate cancer-related deaths decreased 8.7%, whereas deaths because of AD increased 46.1%. Older African-Americans and Hispanics are more likely than older white Americans to have AD or other dementia. Current estimates are that African-Americans are about 2 times more likely, and Hispanics about 1.5 times more likely, than their white counterparts to have these conditions. However, the relationship of race and ethnicity to the development of AD and other dementias is complex and not fully understood. In 2009, nearly 11 million family and other unpaid caregivers provided an estimated 12.5 billion hours of care to persons with AD and other dementias; this care is valued at nearly $144 billion. Medicare payments for services to beneficiaries aged 65 years and older with AD and other dementias are three times higher than for beneficiaries without these conditions. Total payments for 2010 for health care and long-term care services for people aged 65 and older with AD and other dementias are expected to be $172 billion (not including the contributions of unpaid caregivers). An estimated 5.3 million Americans have AD; approximately 200,000 persons under age 65 with AD comprise the younger-onset AD population. Every 70 seconds, someone in America develops AD; by 2050 the time of every 70 seconds is expected to decrease to every 33 seconds. Over the coming decades, the baby boom population is projected to add 10 million people to these numbers. In 2050, the incidence of AD is expected to approach nearly a million people per year, with a total estimated prevalence of 11-16 million people. Dramatic increases in the numbers of "oldest old" (aged 85 years and older) across all racial and ethnic groups will also significantly affect the numbers of people living with AD. This report provides information to increase understanding of the public health effect of AD, including incidence and prevalence, mortality, costs of care, and effect on caregivers and society in general. This report also sets the stage for better understanding the relationship between race and ethnicity and the development of AD and other dementias.