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

Factors Associated With Increased Health Care Utilization for Patients With Dementia With Lewy Bodies: A Narrative Review

Numerous studies have demonstrated that dementia is associated with increased utilization of health care services, which in turn results in increased costs of care. Dementia with Lewy bodies (DLB) is associated with greater costs of care relative to other forms of dementia due to higher rates of hospitalization and nursing home placement directly related to neuropsychiatric symptoms, parkinsonism, increased susceptibility to delirium, and elevated rates of caregiver burden. There is a critical need for researchers to identify potentially modifiable factors contributing to increased costs of care and poor clinical outcomes for patients with DLB, which may include comorbidities, polypharmacy/contraindicated medications, and access to specialty care. Previous research has utilized Medicare claims data, limiting the ability to study patients with early-onset (ie, prior to age 65) DLB. Integrated health systems offer the ability to combine electronic medical record data with Medicare, Medicaid, and commercial claims data and may therefore be ideal for utilization research in this population. The goals of this narrative review are to 1) synthesize and describe the current literature on health care utilization studies for patients with DLB, 2) highlight the current gaps in the literature, and 3) provide recommendations for stakeholders, including researchers, health systems, and policymakers. It is important to improve current understanding of potentially modifiable factors associated with increased costs of care among patients with DLB to inform public health policies and clinical decision-making, as this will ultimately improve the quality of patient care.

Early start of anti-dementia medication is associated with lower health and social care costs in Alzheimer´s patients: a Finnish nationwide register study

OBJECTIVES

To evaluate the association between health and social care costs and early start of anti-dementia medication in a nationwide cohort of Finnish Alzheimer's disease (AD) patients.

METHODS

The cohort included 7454 Finnish AD patients who had their first AD diagnosis in 2012 and lived at home at the time of diagnosis. Data were collected retrospectively from the Finnish national health and social care registers. The primary outcome was 2-year cumulative direct costs after the incident AD diagnosis. The exploratory variable was early anti-dementia medication start (anti-dementia medication started within 3 months of the incident AD diagnosis). Sociodemographic variables, admission to 24-h care and care intensity level, as well as comorbidities were considered as adjusting variables.

RESULTS

Of all patients, 88.9% started AD medication within 3 months of diagnosis. The 2-year cumulative costs were €30,787 and €40,484 per patient for early and late starters, respectively. When adjusted for possible confounders, early start of anti-dementia medication was associated with 26.5% lower 2-year cumulative costs compared to late starters (relative cost 0.735; p < 0.001).

CONCLUSIONS

Early diagnosis and start of anti-dementia medication is important for managing the costs of increasing number of AD patients.

Association of Personal Wealth Indicators and Health Care Costs in Persons With Alzheimer's Disease

OBJECTIVES

There is paucity of studies on the relationship between personal wealth and health care costs among persons with dementia, and earlier studies on other indicators of socioeconomic position have assessed costs after dementia diagnosis only. We investigated how different indicators of personal wealth (disposable income, supplementary income, assets subject to taxation, taxes and tax-like payments, and liabilities) are associated with health care costs in persons with Alzheimer's disease (AD) before and after AD diagnosis.

DESIGN

Register-based nationwide cohort study of persons with AD.

SETTING AND PARTICIPANTS

Cohort of 70,531 people who received a clinically verified AD diagnosis in Finland between 2005 and 2011 and were community-dwelling at time of diagnosis.

METHODS

Data on income indicators were obtained from Statistics Finland. Data on medication costs and hospital care costs for the 12-month period from 5 years before to 2 years after AD diagnosis were obtained from national registers. Associations of wealth indicators with costs were investigated with multivariate mixed-effect negative binomial regression.

RESULTS

After adjustment for age, region, sex, marital status, comorbidities, expensive medications, use of psychotropic and antidementia medication, and highest occupational class before AD, people with higher levels of personal wealth indicators were more likely to have higher total health care costs along the whole follow-up period. The incidence rate ratios (IRRs), 95% CI for highest quintile vs lowest quintile were 1.17, 1.15-1.19 for disposable income, 1.10, 1.08-1.12 for taxable income, 1.18, 1.16-1.19 for supplementary income, 1.07, 1.06-1.09 for taxes, and 1.05, 1.04-1.07 for taxable wealth.

CONCLUSIONS AND IMPLICATIONS

Our observation on the association between income/wealth indicators and health care costs in a country with a strong public health care system call for more effective measures in targeting health inequalities in the aging population. Although the different indicators were not completely interchangeable, associations of different indicators were toward the same direction.

IMOVE: Protocol for a randomized, controlled 2x2 factorial trial of improvisational movement and social engagement interventions in older adults with early Alzheimer's disease

Background

In addition to cognitive impairment, people with Alzheimer's disease (PWAD) experience neuropsychiatric symptoms (e.g., apathy, depression), altered gait, and poor balance that further diminish their quality of life (QoL). Here, we describe a unique, randomized, controlled trial to test the hypothesis that both movement and social engagement aspects of a group dance intervention alter the connectivity of key brain networks involved in motor and social-emotional functioning and lead to improved QoL in PWAD.

Methods

IMOVE (NCT03333837) was a single-center, randomized, controlled 2x2 factorial trial that assigned PWAD/caregiver dyads to one of 4 study conditions (Movement Group, Movement Alone, Social Group, or Usual Care control). The Movement Group participated in twice-weekly group improvisational dance (IMPROVment® Method) classes for 12 weeks. The Movement Alone intervention captured the same dance movement and auditory stimuli as the group class without social interaction, and the Social Group used improvisational party games to recapitulate the fun and playfulness of the Movement Group without the movement. The primary outcome was change in QoL among PWAD. Key secondary outcomes were functional brain network measures assessed using graph-theory analysis of resting-state functional magnetic resonance imaging scans, as well as neuropsychiatric symptoms, gait, and balance.

Results

A total of 111 dyads were randomized; 89 completed the study, despite interruption and modification of the protocol due to COVID-19 restrictions (see companion paper by Fanning et al.). The data are being analyzed and will be submitted for publication in 2023.

SOCS1 Mediates Berberine-Induced Amelioration of Microglial Activated States in N9 Microglia Exposed to β Amyloid

Attenuating β amyloid- (Aβ-) induced microglial activation is considered to be effective in treating Alzheimer's disease (AD). Berberine (BBR) can reduce microglial activation in Aβ-treated microglial cells; the mechanism, however, is still illusive. Silencing of cytokine signaling factor 1 (SOCS1) is the primary regulator of many cytokines involved in immune reactions, whose upregulation can reverse the activation of microglial cells. Microglia could be activated into two different statuses, classic activated state (M1 state) and alternative activated state (M2 state), and M1 state is harmful, but M2 is beneficial. In the present study, N9 microglial cells were exposed to Aβ to imitate microglial activation in AD. And Western blot and immunocytochemistry were taken to observe inducible nitric oxide synthase (iNOS), Arginase-1 (Arg-1), and SOCS1 expressions, and the enzyme-linked immunosorbent assay (ELISA) was used to measure inflammatory and neurotrophic factor release. Compared with the normal cultured control cells, Aβ exposure markedly increased the level of microglial M1 state markers (P < 0.05), including iNOS protein expression, tumor necrosis factor α (TNF-α), interleukin 1β (IL-1β), and IL-6 releases, and BBR administration upregulated SOSC1 expression and the level of microglial M2 state markers (P < 0.05), such as Arg-1 expression, brain-derived neurotrophic factor (BDNF), and glial cell-derived neurotrophic factor (GDNF) releases, downregulating the SOCS1 expression by using siRNA, however, significantly reversed the BBR-induced effects on microglial M1 and M2 state markers and SOCS1 expression (P < 0.05). These findings indicated that BBR can inhibit Aβ-induced microglial activation via modulating the microglial M1/M2 activated state, and SOCS1 mediates the process.

Memorable Food: Fighting Age-Related Neurodegeneration by Precision Nutrition

Healthcare systems worldwide are seriously challenged by a rising prevalence of neurodegenerative diseases (NDDs), which mostly, but not exclusively, affect the ever-growing population of the elderly. The most known neurodegenerative diseases are Alzheimer's (AD) and Parkinson's disease, multiple sclerosis, and amyotrophic lateral sclerosis, but some viral infections of the brain and traumatic brain injury may also cause NDD. Typical for NDD are the malfunctioning of neurons and their irreversible loss, which often progress irreversibly to dementia and ultimately to death. Numerous factors are involved in the pathogenesis of NDD: genetic variability, epigenetic changes, extent of oxidative/nitrosative stress, mitochondrial dysfunction, and DNA damage. The complex interplay of all the above-mentioned factors may be a fingerprint of neurodegeneration, with different diseases being affected to different extents by particular factors. There is a voluminous body of evidence showing the benefits of regular exercise to brain health and cognitive functions. Moreover, the importance of a healthy diet, balanced in macro- and micro-nutrients, in preventing neurodegeneration and slowing down a progression to full-blown disease is evident. Individuals affected by NDD almost inevitably have low-grade inflammation and anomalies in lipid metabolism. Metabolic and lipid profiles in NDD can be improved by the Mediterranean diet. Many studies have associated the Mediterranean diet with a decreased risk of dementia and AD, but a cause-and-effect relationship has not been deduced. Studies with caloric restriction showed neuroprotective effects in animal models, but the results in humans are inconsistent. The pathologies of NDD are complex and there is a great inter-individual (epi)genetic variance within any population. Furthermore, the gut microbiome, being deeply involved in nutrient uptake and lipid metabolism, also represents a pillar of the gut microbiome-brain axis and is linked with the pathogenesis of NDD. Numerous studies on the role of different micronutrients (omega-3 fatty acids, bioactive polyphenols from fruit and medicinal plants) in the prevention, prediction, and treatment of NDD have been conducted, but we are still far away from a personalized diet plan for individual NDD patients. For this to be realized, large-scale cohorts that would include the precise monitoring of food intake, mapping of genetic variants, epigenetic data, microbiome studies, and metabolome, lipidome, and transcriptome data are needed.

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.

Activities of daily living at hospital admission associated with mortality in geriatric patients with dementia: a Danish nationwide population-based cohort study

PURPOSE

Determining life expectancy in patients with dementia are challenging. We aimed at studying the association between basic activities of daily living as measured by the Barthel Index at hospital admission and mortality among older patients with dementia.

METHODS

All patients aged ≥ 65 years with diagnosed dementia in the population-based National Danish Geriatric Database from 2005 to 2014 were included and followed until death, emigration, or study termination (31.12.2015). Data on Barthel Index (BI) were used to assess ADL. Patients were categorized into four predefined standard BI subcategories according to the national Danish version of the statistical classification of diseases [BI = 0-24 (very low ADL), BI = 25-49 (low ADL), BI = 50-79 (moderate reduced ADL), and BI = 80-100 (independent ADL)]. Association with mortality was assessed using multivariable Cox regression analysis adjusting for age, marital status, Charlson Comorbidity Index, BMI, prior hospitalizations, year of admission and polypharmacy.

RESULTS

In total, 6550 patients (women 62%) were included, median (IQR) age 84 (79-88) years and BI 37 (13-63). Mortality increased significantly with decreasing BI in both the crude and multivariable analysis. In subcategories BI = (80-100) and BI = (0-24), survival time (median (95%)) was 3.6 (3.4-3.9) years and 0.8 (0.7-0.9) years, respectively. Also, in patients with BI = (0-24), the overall mortality risk (HR (95% CI)) was 2.5 (2.2-2.8), 30-day risk 11.8 (5.8-23.9), and 1-year risk 4.4 (3.6-5.5) when using BI = (80-100) as reference.

CONCLUSION

Barthel Index is independently associated with all-cause mortality among older patients with dementia admitted to hospital. BI may be a helpful tool for clinicians when discussing treatment and care strategies with patients and their families.

The outcome and burden of Chinese patients with neurodegenerative diseases: A 10-year clinical feature study

BACKGROUND

As the Chinese population continues to age, the incidence of neurodegenerative diseases (NDDs) has increased dramatically, which results in heavy medical and economic burden for families and society.

OBJECTIVE

The objective of this study was to evaluate NDDs in a southern Chinese hospital over a 10-year period and examine trends in demographics, outcome, length of stay (LOS) and cost.

METHODS

Retrospective medical records of patients from January 2010 to December 2019 were collected, including 7231 patients with NDDs (as case group) and 9663 patients without any NDDs (as control group). The information of social demographic data, admission source, reasons for admission, outcomes, LOS, and cost were extracted and analysed.

RESULT

The average hospitalisation age of the patients with NDDs is over 65 years (peak age 70-89 years). Compared with the control group, the case group had a longer LOS and a higher cost and the numbers of patients with NDDs increased yearly from 2010 to 2019. The LOS shortened while the cost increased. Clinical features affected LOS and cost. Patients suffering from infection, abnormal blood pressure and the imbalance of water-electrolyte homoeostasis as main reasons for admission were decreased; however, heart disease, cerebrovascular accident and mental diseases were significantly increased, the overall change trend of fracture/trauma remained stable. The rate of discharge to home care and mortality declined; discharge to other medical or community facilities increased over 10 years.

CONCLUSION

The majority of NDDs patients tended to be older. During the last 10 years from 2010 to 2019, the numbers of NDDs patients increased yearly, the trend of LOS became shortening and the cost gradually increasing. The main reasons of admission and outcomes of hospital showed different trends.