Hospital admissions, outpatient visits and healthcare costs of community-dwellers with Alzheimer's disease

Patterns of unplanned hospital admissions among people with dementia: from diagnosis to the end of life

BACKGROUND

hospitalisations are sentinel events for people with dementia. How patterns of unplanned hospital admissions change among people with dementia after diagnosis is relatively unknown.

OBJECTIVE

to describe patterns of unplanned hospital admissions of people with dementia from diagnosis until death/study end.

METHODS

retrospective cohort study using mental healthcare provider data of people diagnosed with dementia in London, UK (1995-2017), linked to mortality and hospital data. The primary outcome was the rate of unplanned hospital admissions after diagnosis until death/study end. We calculated the cumulative incidence of unplanned hospital admissions. The rates of unplanned hospital admissions and the percentage of time spent as an inpatient were stratified by time from first dementia diagnosis.

RESULTS

for 19,221 people with dementia (61.4% female, mean age at diagnosis 81.0 years (standard deviation, SD 8.5)), the cumulative incidence of unplanned hospital admissions (n = 14,759) was 76.8% (95% CI 76.3%-77.3%). Individuals remained in the study for mean 3.0 (SD 2.6) years, and 12,667 (65.9%) died. Rates and lengths of unplanned hospital admissions remained relatively low and short in the months after the dementia diagnosis, increasing only as people approached the end of life. Percentage of time spent as an inpatient was <3% for people who were alive at the study end but was on average 19.6 and 13.3% for the decedents in the last 6 and 12 months of life, respectively.

CONCLUSIONS

the steep rise in hospitalisations before death highlights the need for improved community care and services for people with dementia who are approaching the end of life.

Association of recent hospitalisation with antidepressant initiation among community dwellers with Alzheimer's disease

OBJECTIVES

Antidepressant are commonly prescribed to persons with cognitive disorders to treat depressive and other neuropsychiatric symptoms despite the inconclusive evidence on their effectiveness on this indication. We studied whether recent hospitalisation was associated with antidepressant initiation in people with Alzheimer's disease (AD).

METHODS

The register-based Finnish nationwide Medication use and Alzheimer's disease cohort includes community-dwelling persons diagnosed with AD during 2005-2011 in Finland (n = 70,718). This study was restricted to people who initiated antidepressant use after AD diagnosis and had no active cancer treatment and schizophrenia or bipolar disorder diagnoses. We performed a nested case-control study with antidepressant initiators as cases. A matched noninitiator (sex, age and AD duration), was identified for each initiator (15,360 matched pairs). Recent hospitalisation was defined as hospital discharge within the past 14 days of initiation.

RESULTS

Antidepressant initiators were four times more likely (adjusted odds ratio: 4.41, 95% confidence interval: 4.06-4.80) to have been hospitalised within the past 2 weeks before initiation (21.2%, n = 3250) than matched noninitiators (5.4%, n = 831) and the duration of hospital stay was significantly longer among initiators. Dementia was the most common main discharge diagnosis among both initiators (43.8%, n = 1423) and noninitiators (24.8%, n = 206).

CONCLUSION

Recent hospitalisation was strongly associated with antidepressant initiation in persons with AD. Further studies are needed to investigate whether this is due to neuropsychiatric symptoms leading to hospital admission, inpatient care triggering or worsening neuropsychiatric symptoms or other indications. Nonpharmacological treatments for neuropsychiatric symptoms should be prioritised and the threshold for prescribing antidepressants should be high.

Dementia identified as a risk factor for infection-related hospital contacts in a national, population-based and longitudinal matched-cohort study

The aim of this study was to investigate the association between incident dementia and rates of infection-related hospital contacts. We conducted a registry- and population-based matched-cohort study of all Danish residents who were born in or before 1950, included from 1 January 2000 or their 65th birthday (whichever came later), who were alive and resided in Denmark at the start of the study, excluding those who had received a dementia diagnosis before 1 January 2000 or their 65th birthday (n = 1,712,100). A total of 129,660 people (403,744 person years) with incident dementia were matched with 297,476 people (1,918,784 person years) without dementia. Incidence rate ratios (IRRs) of infection-related hospital contacts were calculated using Poisson regression, by infection type, sex and age. The IRR for any infection-related contact in dementia was 1.5, was highest for nervous and urinary system infections and sepsis, decreased with increasing age and was higher in men. More people with than without dementia had contacts five years before the index date. Our findings show that dementia is a risk factor for infection-related hospital contacts and infections might be an early sign of dementia.

Highly frequent utilization of outpatient services in a national health insurance system - analysis of associated factors and underlying co-morbidity

OBJECTIVE

We aimed to identify associated factors of highly frequent use of outpatient services and explore how they were impacted to provide policy references for government and medical institutes in their efforts to seek provision of reasonable medical services, continuous care and integrated outpatient services.

METHODS

The Taiwanese national health insurance database was used and 661,125 patients were identified in 2009. The patients with ≥100 internal medicine outpatient (IMO) visits were defined as the highly frequent group and they were matched at a ratio of 1:4 with patients of 1-99 IMO visits based on demographic characteristics. Multivariate logistic regression was used to estimate adjusted odds ratios with 95% confidence intervals.

RESULTS

Among 1 million patients in the outpatient department, 0.05% had at least 100 visits. These patients with highly frequent IMO visits had significantly higher rates of emergency department (ED) visits, hospitalization, psychiatric disorders and possession of a catastrophic illness card as well as a significantly lower level of continuity of care index (COCI). Multivariate analysis showed that ED visits (adjusted OR [AOR] = 1.63), psychiatric disorders (AOR = 7.13), low COCI (AOR = 1.69), and several comorbidities including peripheral vascular diseases (AOR = 4.33), dementia (AOR = 0.04), chronic pulmonary disease (AOR = 3.02), peptic ulcer diseases (AOR = 3.70), diabetes mellitus (AOR = 3.45) and renal disease (AOR = 2.43) were significant associated factors.

CONCLUSIONS

To rationalize use and distribution of medical resources, we suggest proper regular care and health education to those with mental disabilities and multiple chronic conditions, which may not only improve the situation of highly frequent hospital visits but also effectively control incidence of acute conditions and reduce their ED visits. In addition, improving the continuity of care is vital, and the best way to do this is to promote family medicine as the primary form of healthcare.

Trajectories of health system use and survival for community-dwelling persons with dementia: a cohort study

OBJECTIVES

To determine the long-term trajectories of health system use by persons with dementia as they remain in the community over time.

DESIGN

Population-based cohort study using health administrative data.

SETTING

Ontario, Canada from 1 April 2007 to 31 March 2014.

PARTICIPANTS

62 622 community-dwelling adults aged 65+ years with prevalent dementia on 1 April 2007 matched 1:1 to persons without dementia based on age, sex and comorbidity.

MAIN OUTCOME MEASURES

Rates of health service use, long-term care placement and mortality over time.

RESULTS

After 7 years, 49.0% of persons with dementia had spent time in long-term care (6.8% without) and 64.5% had died (30.0% without). Persons with dementia were more likely than those without to use home care (rate ratio (RR) 3.02, 95% CI 2.93 to 3.11) and experience hospitalisations with a discharge delay (RR 2.36, 95% CI 2.30 to 2.42). As they remained in the community, persons with dementia used home care at a growing rate (10.7%, 95% CI 10.0 to 11.3 increase per year vs 6.7%, 95% CI 4.3 to 9.0 per year among those without), but rates of acute care hospitalisation remained constant (0.6%, 95% CI -0.6 to 1.9 increase per year).

CONCLUSIONS

While persons with dementia used more health services than those without dementia over time, the rate of change in use differed by service type. These results, particularly enumerating the increased intensity of home care service use, add value to capacity planning initiatives where limited budgets require balancing services.

The association between dementia severity and hospitalisation profile in a newly assessed clinical cohort: the South London and Maudsley case register

OBJECTIVES

To evaluate the risk and common causes of hospitalisation in patients with newly diagnosed dementia and variation by severity of cognitive impairment.

SETTING

We used data from a large London mental healthcare case register linked to a national hospitalisation database.

PARTICIPANTS

Individuals aged ≥65 years with newly diagnosed dementia with recorded cognitive function and the catchment population within the same geography.

OUTCOME MEASURES

We evaluated the risk and duration of hospitalisation in the year following a dementia diagnosis. In addition we identified the most common causes of hospitalisation and calculated age-standardised and gender-standardised admission ratios by dementia severity (mild/moderate/severe) relative to the catchment population.

RESULTS

Of the 5218 patients with dementia, 2596 (49.8%) were hospitalised in the year following diagnosis. The proportion of individuals with mild, moderate and severe dementia who had a hospital admission was 47.9%, 50.8% and 51.7%, respectively (p= 0.097). Duration of hospital stay increased with dementia severity (median 2 days in mild to 4 days in severe dementia, p 0.0001). After excluding readmissions for the same cause, the most common primary hospitalisation discharge diagnoses among patients with dementia were urinary system disorders, pneumonia and fracture of femur, accounting for 15%, 10% and 6% of admissions, respectively. Overall, patients with dementia were hospitalised 30% more than the catchment population, and this trend was observed for most of the discharge diagnoses evaluated. Standardised admission ratios for urinary and respiratory disorders were higher in those with more severe dementia at diagnosis.

CONCLUSIONS

Individuals with a dementia diagnosis were more likely to be hospitalised than individuals in the catchment population. The length of hospital stay increased with dementia severity. Most of the common causes of hospitalisation were more common than expected relative to the catchment population, but standardised admission ratios only varied by dementia stage for certain groups of conditions.

Comorbid conditions and emergency department treat and release utilization in multimorbid persons with cognitive impairment

BACKGROUND

There is an increasing focus in the emergency department (ED) on addressing the needs of persons with cognitive impairment, most of whom have multiple chronic conditions. We investigated which common comorbidities among multimorbid persons with cognitive impairment conferred increased risk for ED treat and release utilization.

METHODS

We examined the association of 16 chronic conditions on use of ED treat and release visit utilization among 1006 adults with cognitive impairment and ≥ 2 comorbidities using the nationally-representative National Health and Aging Trends Study merged with Fee-For-Service Medicare claims data, 2011-2015.

RESULTS

At baseline, 28.5% had ≥6 conditions and 35.4% were ≥ 85 years old. After controlling for sex, age, race, education, urban-living, number of disabled activities of daily living, and sampling strata, we found significantly increased adjusted risk ratios (aRR) of ED treat and release visits for persons with depression (aRR 1.38 95% CI 1.15-1.65) representing 78/100 person-years, and osteoarthritis or rheumatoid arthritis (aRR 1.32 95% CI 1.12-1.57) representing 71/100 person-years. At baseline 93.9% had ≥1 informal caregiver and 69.7% had a caregiver that helped with medications or attended physician visits.

CONCLUSION

These results show that multimorbid cognitively impaired older adults with depression or osteoarthritis or rheumatoid arthritis are at higher risk of ED treat and release visits. Future ED research with multimorbid cognitively impaired persons may explore behavioral aspects of depression and/or pain and flairs associated with osteoarthritis or rheumatoid arthritis, as well as the role of informal caregivers in the care of these conditions.

Regional Cerebral Blood Flow in the Posterior Cingulate and Precuneus and the Entorhinal Cortical Atrophy Score Differentiate Mild Cognitive Impairment and Dementia Due to Alzheimer Disease

BACKGROUND AND PURPOSE

Alzheimer disease is the most common degenerative dementia affecting humans and mild cognitive impairment is considered the forerunner of this devastating illness with variable progression. Differentiating between them has become all the more essential with the advent of disease-modifying medications. The aim of this study was to test the utility of the entorhinal cortical atrophy score in combination with quantitative CBF in the posterior cingulate and precuneus using arterial spin-labeling to differentiate mild cognitive impairment and early Alzheimer disease.

MATERIALS AND METHODS

We analyzed MR imaging from a prospective data base of 3 age-matched groups: 21 cognitively healthy controls, 20 patients with mild cognitive impairment, and 19 patients with early Alzheimer disease. The highest entorhinal cortical atrophy score and an atlas-based measurement of CBF in the posterior cingulate and precuneus were estimated in these groups. Statistical comparison was performed among the groups for disease-prediction probability with these parameters independently and in combination using a binary logistic regression model.

RESULTS

The entorhinal cortical atrophy score performed well in distinguishing AD from HC, with a predicted probability of .887 (area under the curve, P < .001). The mean CBF of the posterior cingulate and precuneus was also found to be a useful discriminator (area under the curve, 0.810, P = < .001). Combining the entorhinal cortical atrophy score and CBF was the best predictor (area under the curve, 0.957, P < .001). In distinguishing mild cognitive impairment and Alzheimer disease, entorhinal cortical atrophy also did well with an area under the curve of 0.838 (P < .001). However regional CBF was not useful in differentiating them (area under the curve = 0.589, P = .339). Entorhinal cortical atrophy scored poorly in distinguishing mild cognitive impairment from healthy controls (AUC = 0.571, P = .493), but CBF fared well, with an area under the curve of 0.776 (P = .002).

CONCLUSIONS

Combining entorhinal cortical atrophy and regional CBF could be a potential imaging biomarker in distinguishing mild cognitive impairment and Alzheimer disease.

Predictors of high hospital care and medication costs and cost trajectories in community-dwellers with Alzheimer's disease

Objectives: We studied the determinants of high healthcare costs (highest decile of hospital care and medication costs) and cost trajectories among all community-dwellers with clinically verified Alzheimer's disease (AD), diagnosed during 2005-2011 in Finland (N = 70,531). Methods: The analyses were done separately for hospital care costs, medication costs and total healthcare costs that were calculated for each 6-month period from 5 years before to 3 years after AD diagnosis. Results: Total healthcare costs were driven mainly by hospital care costs. The definition of "high-cost person" was time-dependent as 63% belonged to the highest 10% at some timepoint during the study period and six distinct cost trajectories were identified. Strokes, cardiovascular diseases, fractures and mental and behavioural disorders were most strongly associated with high hospital care costs. Conclusions: Although persons with AD are often collectively considered as expensive patient group, there is large temporal and inter-individual variation in belonging to the highest decile of hospitalization and/or medication costs. It would be important to assess whether hospitalization rate could be decreased by, e.g., comprehensive outpatient care with more efficient management of comorbidities. In addition, other interventions that could decrease hospitalization rate in persons with dementia should be studied further in this context. Key messages Persons with AD had large individual fluctuation in hospital care costs and medication costs over time. Hospital care costs were considerably larger than medication costs, with fractures, cardiovascular diseases and mental and behavioural disorders being the key predictors. Antidementia medication was associated with lower hospital care costs.

Hospitalization after Oral Antibiotic Initiation in Finnish Community Dwellers with and without Alzheimer's Disease: Retrospective Register-Based Cohort Study

BACKGROUND

Persons with Alzheimer's disease (AD) are frequently hospitalized from infection-related causes. There are no previous studies investigating hospitalization associated with antibiotic initiation in persons with AD.

OBJECTIVE

To investigate the frequency and risk of hospitalization associated with oral antibiotic initiation among community dwellers with and without AD.

METHODS

We performed a retrospective register-based study utilizing register-based Medication Use and Alzheimer's disease (MEDALZ) cohort. It includes all community dwellers diagnosed with AD during 2005-2011 in Finland and their matched comparison persons without AD. Antibiotic use was initiated by 34,785 persons with and 36,428 without AD. Drug use data were collected from Prescription Register and comorbidities from Special Reimbursement and Hospital Care Registers. Infection diagnoses were collected from the Hospital Care Register. Factors associated with hospitalization were estimated utilizing logistic regression models.

RESULTS

Risk of hospitalization following antibiotic initiation was higher among antibiotic initiators with AD than without AD (adjusted odds ratio, aOR, 1.37, 95% Cl 1.28-1.46).Strongest association with hospitalization was found for oral glucocorticoid use, aOR 1.41 (1.25-1.59); epilepsy, aOR 1.33 (1.10-1.63); and active cancer, aOR 1.30 (1.14-1.49). Among initiators of cephalexin, pivmecillinam, amoxicillin/amoxicillin, and enzyme inhibitor and doxycycline, persons with AD were more frequently hospitalized than persons without AD. A quarter of hospitalized antibiotic initiators had infection diagnosis in their hospital care records.

CONCLUSIONS

Persons with AD initiating an antibiotic had a higher risk for hospitalization than antibiotic initiators without AD. Further research is needed to determine whether infection-related hospitalization could be reduced.

Hospitalisation rates and predictors in people with dementia: a systematic review and meta-analysis

BACKGROUND

Hospitalisation is often harmful for people with dementia and results in high societal costs, so avoidance of unnecessary admissions is a global priority. However, no intervention has yet reduced admissions of community-dwelling people with dementia. We therefore aimed to examine hospitalisation rates of people with dementia and whether these differ from people without dementia and to identify socio-demographic and clinical predictors of hospitalisation.

METHODS

We searched MEDLINE, Embase, and PsycINFO from inception to 9 May 2019. We included observational studies which (1) examined community-dwelling people with dementia of any age or dementia subtype, (2) diagnosed dementia using validated diagnostic criteria, and (3) examined all-cause general (i.e. non-psychiatric) hospital admissions. Two authors screened abstracts for inclusion and independently extracted data and assessed included studies for risk of bias. Three authors graded evidence strength using Cochrane's GRADE approach, including assessing for evidence of publication bias using Begg's test. We used random effects meta-analysis to pool estimates for hospitalisation risk in people with and without dementia.

RESULTS

We included 34 studies of 277,432 people with dementia: 17 from the USA, 15 from Europe, and 2 from Asia. The pooled relative risk of hospitalisation for people with dementia compared to those without was 1.42 (95% confidence interval 1.21, 1.66) in studies adjusted for age, sex, and physical comorbidity. Hospitalisation rates in people with dementia were between 0.37 and 1.26/person-year in high-quality studies. There was strong evidence that admission is associated with older age, and moderately strong evidence that multimorbidity, polypharmacy, and lower functional ability are associated with admission. There was strong evidence that dementia severity alone is not associated.

CONCLUSIONS

People with dementia are more frequently admitted to hospital than those without dementia, independent of physical comorbidities. Future interventions to reduce unnecessary hospitalisations should target potentially modifiable factors, such as polypharmacy and functional ability, in high-risk populations.

Length of hospital stay and dementia: A systematic review of observational studies

OBJECTIVE

Hospitalizations of people with dementia (PWD) are often accompanied by complications or functional loss and can lead to adverse outcomes. Unsystematic findings suggest an influence of comorbidities on the extent of differences in the length of hospital stay (LOS). This systematic review aimed to identify and evaluate all studies reporting LOS in PWD as compared to PwoD in general hospitals.

METHODS

A systematic review of observational studies using PubMed and ISI Web of Knowledge. Inclusion criteria comprised original studies written in English or German, assessment of diagnosis of dementia, measurement of LOS, and comparison of people with and without dementia.

RESULTS

Fifty-two of 60 studies reported a longer hospitalization time for PWD compared to PwoD. The extent of the difference in LOS varied between and within countries as well as by type of primary morbidity (eg, injuries, cardiovascular diseases). The range of the LOS difference for studies without restriction to a primary morbidity was -2 to +22 days after matching or adjustment for a variable number and selection of potentially relevant covariates. For studies with injuries/fractures/medical procedures and infectious/vascular disease as the primary morbidity, the range was -2.9 to +12.4 and -11.2 to +21.8 days, respectively.

CONCLUSIONS

The majority of studies reported a longer hospitalization of PWD compared to PwoD. Length of hospital stay seems to be influenced by a variety of medical, social, organizational factors, including reasons for hospital admission, whose role should be explored in detail in further research.

The Prevalence of Dementia and Cognitive Impairment in Hospitals

BACKGROUND

The care of elderly patients with comorbid dementia poses an increasing challenge in the acute inpatient setting, yet there remains a lack of representative studies on the prevalence and distribution of dementia in general hospitals.

METHODS

We conducted a cross-sectional study of patients aged 65 and older in randomly selected general hospitals in southern Germany. Patients were excluded if they were in an intensive care unit or isolation unit or if they were on specialized wards for psychiatry, neurology, or geriatric medicine. The findings are derived from patient interviews, neuropsychological testing, standardized rating scales, questioning of nursing staff, and the patients' medical records.

RESULTS

1469 patients on 172 inpatient wards of 33 hospitals were studied. 40.0% of them (95% confidence interval, [36.2; 43.7]) had at least mild cognitive impairment. The point-prevalence of dementing illnesses was 18.4% [16.3; 20.7]. Delirium, most often on the basis of dementia, was present in 5.1% [3.9; 6.7]. 60.0% had no cognitive impairment. Dementia was more common among patients of very advanced age, those who were dependent on nursing care, those who lived in old-age or nursing homes, and those with a low level of education. Among patients with dementia, only 36.7% had a documented diagnosis of dementia in the medical record. Patients with dementia were treated more often for dehydration, electrolyte disturbances, urinary tract infections, contusions, and bone fractures, as well as for symptoms and findings of an unknown nature, and much less often for cancer or musculoskeletal diseases.

CONCLUSION

Two out of five elderly patients in general hospitals suffer from a cognitive disturbance. Patients with severe impairments such as dementia or delirium often need special care. Guidelines and model projects offer approaches by which the inpatient care of patients with comorbid dementia can be improved.

Hospital admissions 2000-2014: A retrospective analysis of 288 096 events in patients with dementia

INTRODUCTION

Dementia is a leading cause of disability worldwide. It is associated with an increased risk of hospitalization, imposing a significant burden on healthcare systems. The evidence on the long-term evolution of this issue and broadly on healthcare systems is currently limited. This study aims to describe the hospitalizations of people who received a diagnosis of dementia admitted to public general hospitals in a western European country with universal health coverage, over more than a decade.

METHODS

This retrospective observational study analyzed all inpatient episodes from 2000 to 2014 with a primary or secondary diagnosis of dementia using a national hospitalization database from mainland Portuguese public hospitals.

RESULTS

A total of 288 096 hospital admissions were registered. Hospitalization rates increased 4.7 times throughout the study period. Pneumonia and urinary tract infections were the most frequent main diagnoses, while dementia itself was the cause of admission in a minority (6.8%) of cases. Cerebrovascular disease, diabetes without chronic complications, and congestive heart failure were the most prevalent comorbidities; 5.9% of patients with dementia admitted to hospital underwent a surgical procedure, orthopedic surgeries being the most frequent. The median length of hospital stay was 8.0 days, and in-hospital mortality rate was 16.1%.

CONCLUSIONS

Dementia patients represent a significant amount of hospital admissions. Most leading causes of hospital admissions are preventable if timely diagnosed and could be effectively managed in the outpatient setting. These findings may be useful for healthcare resource planning and allocation. Further research should drive evidence-based reorganization of health care systems.

Risk of death associated with new benzodiazepine use among persons with Alzheimer disease: A matched cohort study

OBJECTIVE

To investigate the risk of death associated with new benzodiazepine and related drug (BZDR) use in a nationwide cohort of persons with Alzheimer disease (AD).

METHODS

The register-based MEDALZ cohort, including all community-dwelling Finns diagnosed with AD during 2005 to 2011 (n = 70 718), was used. Clinically verified AD diagnoses were obtained from the Special Reimbursement Register. Drug use periods were modeled from BZDR purchases, derived from the Prescription Register. To study new users, persons who had any BZDR use during the year preceding the AD diagnosis were excluded. For each person initiating BZDR use (n = 10 380), 2 nonusers (n = 20 760) were matched on age, gender, and time since AD diagnosis. The outcome was 180-day mortality, and BZDR use was compared with nonuse with Cox regression. Multivariable analyses were adjusted for Charlson comorbidity index, socioeconomic position, hip fractures, psychiatric disorders, substance abuse, stroke, and other psychotropic drug use.

RESULTS

During the follow-up, 5 excess deaths per 100 person-years occurred during BZDR use in comparison to nonuse, and mortality rates were 13.4 (95% confidence interval [CI], 12.2-14.5) and 8.5 (95% CI, 7.9-9.1), respectively. Benzodiazepine and related drug use was associated with an increased risk of death (adjusted hazard ratio = 1.4 [95% CI, 1.2-1.6]), and the association was significant from the initiation of use. Benzodiazepine use was associated with an increased risk of death, whereas benzodiazepine-related drug use was not.

CONCLUSIONS

Benzodiazepine and related drug use was associated with an increased risk of death in persons with AD. Our results support treatment guidelines stating that nonpharmacological approaches should be the first-line option for symptomatic treatment of AD.

Determinants of hospitalization and length of stay among people with dementia - An analysis of statutory health insurance claims data

OBJECTIVE

Dementia is a crucial challenge in acute care hospitals. Using a retrospective claims data cohort, this paper explores dementia patients' acute hospitalization rates, risk factors, and length of stay.

METHODS

The study used claims data from AOK PLUS, the largest statutory health insurance service (SHI) in Saxony, a federal state of Germany. The analysis included 61,239 people with dementia and 183,477 control subjects, all 65 years and older. Control subjects were age, gender, and regionally matched in a 1:3 ratio. Negative binomial hurdle regression was used to compare differences in hospitalization for the year 2014.

RESULTS

People with dementia had 1.49 times higher adjusted odds of being hospitalized at least once (95% confidence interval [CI], 1.46-1.52). Among those individuals hospitalized at least once, dementia increased the number of readmissions by 18% (95% CI, 1.15-1.20). Dementia patients also had a 1.74 times higher odds for at least one emergency admission compared to individuals without dementia (95% CI, 1.70-1.78). Dementia patients' admission risk factors included having care dependency, being recently diagnosed with dementia and living outside a metropolitan region. The increased length of stay for people with dementia per year was mainly attributable to higher admission rates.

CONCLUSIONS

Dementia patients are at higher risk for hospitalization, especially if they live outside the metropolitan region. Healthcare systems need to respond to the challenges resulting from the predicted demographic developments and increasing burden of dementia in the general population.

Hospitalization in people with dementia with Lewy bodies: Frequency, duration, and cost implications

Introduction

Increased hospitalization is a major component of dementia impact on individuals and cost, but has rarely been studied in dementia with Lewy bodies (DLB). Our aim was to describe the risk and duration of hospital admissions in patients with DLB, and compare these to those in Alzheimer's disease (AD) and the general population.

Methods

A large database of mental health and dementia care in South London was used to assemble a cohort of patients diagnosed with DLB. These were 1:4 matched with patients diagnosed with AD on age, gender, and cognitive status.

Results

Rates of hospital admissions in the year after dementia diagnosis were significantly higher in 194 patients with DLB than in 776 patients with AD (crude incidence rate ratio 1.50; 95% confidence interval: 1.28-1.75) or the catchment population (indirectly standardized hospitalization rate 1.22; 95% confidence interval: 1.06-1.39). Patients with DLB had on average almost four additional hospital days per person-year than patients with AD. Multivariate Poisson regression models indicated poorer physical health early in the disease course as the main driver of this increased rate of hospitalization, whereby neuropsychiatric symptoms additionally explained the higher number of hospital days.

Discussion

Patients with DLB are more frequently admitted to general hospitals and utilize inpatient care to a substantially higher degree than patients with AD or the general elderly population. These data highlight an opportunity to reduce hospital days by identifying DLB earlier and providing more targeted care focused on the specific triggers for hospitalization and associations of prolonged stay.

The social and economic burden of frontotemporal degeneration

Objective:

To quantify the socioeconomic burden of frontotemporal degeneration (FTD) compared to previously published data for Alzheimer disease (AD).

Methods:

A 250-item internet survey was administered to primary caregivers of patients with behavioral-variant FTD (bvFTD), primary progressive aphasia, FTD with motor neuron disease, corticobasal syndrome, or progressive supranuclear palsy. The survey included validated scales for disease staging, behavior, activities of daily living, caregiver burden, and health economics, as well as investigator-designed questions to capture patient and caregiver experience with FTD.

Results:

The entire survey was completed by 674 of 956 respondents (70.5%). Direct costs (2016 US dollars) equaled $47,916 and indirect costs $71,737, for a total annual per-patient cost of $119,654, nearly 2 times higher than reported costs for AD. Patients ≥65 years of age, with later stages of disease, and with bvFTD correlated with higher direct costs, while patients <65 years of age and men were associated with higher indirect costs. An FTD diagnosis produced a mean decrease in household income from $75,000 to $99,000 12 months before diagnosis to $50,000 to $59,999 12 months after diagnosis, resulting from lost days of work and early departure from the workforce.

Conclusions:

The economic burden of FTD is substantial. Counting productivity-related costs, per-patient costs for FTD appear to be greater than per-patient costs reported for AD. There is a need for biomarkers for accurate and timely diagnosis, effective treatments, and services to reduce this socioeconomic burden.

Regional Cerebral Blood Flow in Mild Cognitive Impairment and Alzheimer's Disease Measured with Arterial Spin Labeling Magnetic Resonance Imaging

Alzheimer's disease (AD) depicts dynamic changes in regional brain function from early stages of the disease. Arterial spin labeling- (ASL-) based MRI methods have been applied for detecting regional cerebral blood flow (rCBF) perfusion changes in patients with AD and mild cognitive impairment (MCI). Nevertheless, the results obtained from ASL studies in AD and MCI are still controversial, since rCBF maps may show both hypoperfusion or hyperperfusion areas in brain structures involved in different cognitive functions. The goal of this review is to provide the current state of the art regarding the role of ASL for detecting distinctive perfusion patterns in subjects with MCI and/or AD. The ability to obtain this information using a noninvasive and widely available modality such as ASL should greatly enhance the knowledge into the broad range of hemodynamically related changes taking place during the cognitive decline process in AD.

Monetary costs of Alzheimer's disease in China: protocol for a cluster-randomised observational study

Background

Alzheimer’s disease (AD) is the most common type of dementia. International multilateral cost-of-illness (COI) studies have revealed that the cost of treating this disease is huge, which places a significant burden on patients’ families and their healthcare systems. However, no such studies have been conducted in China. This study estimates the monetary costs of patients with AD in mainland China.

Methods

This study planned to start in October 2015 and to finish in March 2016. It covered 30 provincial, municipal, and autonomous regions in mainland China. The sites and research centres in each region were selected randomly. The participating sites include Tier 3 hospitals, psychiatric hospitals, geriatric hospitals, nursing homes, and residences. More than 2500 patients with AD and their caregivers from all of the 81 research centres will be enrolled to fulfil the calculated sample size. The monetary costs of AD, which include direct medical costs, direct non-medical costs, and indirect costs, are being collected using the electronic medical record system and residence health system at each site; face-to-face interviews are being performed when necessary. Descriptive statistics will be used to summarise the patient characteristics and generalised linear models will be developed to calculate the costs.

Results

The main findings will include national and per patient annual monetary costs of AD in China.

Conclusions

To the best of our knowledge, this is the first large-scale cluster-randomized observational study to estimate the economic burden of AD in Chinese patients. The methodology used was based on China’s current healthcare system and is suitable for the purpose of the study. Because the burden of AD on patients, families, healthcare providers, and society is substantial and increasing, it is important and necessary to understand the economic burden caused by this disease.

Trial registration

Our trial was retrospectively registered on ClinicalTrials.gov, NCT02694445, registered on 02/26/2016

Long-term use of antipsychotics in community-dwelling dementia patients: prevalence and profile accounting for unobservable time bias because of hospitalization

The aim of this study was to assess the prevalence of long-term antipsychotic (AP) use in community-dwelling patients with dementia considering hospitalization periods as AP exposure or not. A retrospective study was carried out from 2009 to 2012 on a PACA-Alzheimer cohort (which included 31 963 patients in 2009 and 36 442 in 2012 from 5 million inhabitants). Three groups of patients were identified according to the longest exposure to APs without interruption: nonusers, short-term users (≤3 successive months without discontinuation), and long-term users. Sensitivity analyses on hospitalization periods were carried out. The percentage of patients with at least one AP dispensing was stable over the study period (25.6% in 2009 vs. 26.5% in 2012). In 2012, 27.6% were AP long-term users. This increased to 46.7% when hospitalization periods were counted as AP exposure. In comparison with nonusers, AP users took more benzodiazepines and antidepressants. Short-term users were men [odds ratio (OR)=1.2, 95% confidence interval (CI) (1.1-1.3)] older than 85 years old [OR=1.2, 95% CI (1.1-1.2)]. Long-term users were more exposed to benzodiazepines [OR=1.2, 95% CI (1.1-1.4)]. This study showed that long-term use of AP remained frequent in community-dwelling patients with dementia. It also showed that the prevalence of long-term users almost doubled when hospitalization periods were counted as AP exposure. This underlines the need to consider hospitalization periods when assessing medication exposure in populations with frequent periods of hospitalization.

Cohort profile: the Finnish Medication and Alzheimer's disease (MEDALZ) study

PURPOSE

The aim of the Medicine use and Alzheimer's disease (MEDALZ) study is to investigate the changes in medication and healthcare service use among persons with Alzheimer's disease (AD) and to evaluate the safety and effectiveness of medications in this group. This is important, because the number of persons with AD is rapidly growing and even though they are a particularly vulnerable patient group, the number of representative, large-scale studies with adequate follow-up time is limited.

PARTICIPANTS

MEDALZ contains all residents of Finland who received a clinically verified diagnosis of AD between 2005 and 2011 and were community-dwelling at the time of diagnosis (N=70 719). The diagnosis is based on the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCS-ADRDA) and Diagnostic and Statistical Manual Fourth Edition (DSM-IV) criteria for Alzheimer's disease. The cohort contains socioeconomic data (education, occupational status and taxable income, 1972-2012) and causes of death (2005-2012), data from the prescription register (1995-2012), the special reimbursement register (1972-2012) and the hospital discharge register (1972-2012). Future updates are planned.The average age was 80.1 years (range 34.5-104.6 years). The majority of cohort (65.2%) was women. Currently, the average length of follow-up after AD diagnosis is 3.1 years and altogether 26 045 (36.8%) persons have died during the follow-up.

FINDINGS

Altogether 53% of the cohort had used psychotropic drugs within 1 year after AD diagnoses. The initiation rate of for example, benzodiazepines and related drugs and antidepressants began to increase already before AD diagnosis.

FUTURE PLANS

We are currently assessing if these, and other commonly used medications are related to adverse events such as death, hip fractures, head injuries and pneumonia.

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

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