Direct and indirect cost of managing alzheimer's disease and related dementias in the United States

Serum zinc concentration and dietary zinc intake in relation to cognitive function: an analysis of the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort

PURPOSE

There are several pathways by which zinc may be a modifiable factor to slow age-related cognitive decline. We investigated the associations between serum and dietary zinc and cognitive impairment in a longitudinal cohort.

METHODS

We used data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort (n = 30,239) and the REGARDS Trace Element Study (n = 2666). Baseline serum zinc concentrations (2003-2007) were measured using inductively coupled plasma mass spectrometry. Baseline dietary zinc intake was measured via the Block food frequency questionnaire. Serum zinc concentrations and dietary zinc intake were categorized into quartiles. The outcome of interest was impairment on the Six-Item Screener (SIS), a measure of global cognitive functioning administered annually. The Enhanced Cognitive Battery (ECB), a more comprehensive series of tests assessing memory and fluency, was administered every two years and considered a secondary outcome. Associations between zinc and incident impairment were assessed using multivariable logistic regression.

RESULTS

Among 2065 participants with serum zinc data, 184 individuals developed impairment over 10 years of follow-up. In adjusted models, there was no significant association between serum zinc and impairment as assessed by the SIS or the ECB. Among 18,103 participants who had dietary data, 1424 experienced incident impairment on the SIS. Dietary zinc intake was not significantly associated with impairment as assessed by the SIS or the ECB in adjusted models.

CONCLUSION

Findings from this U.S. cohort did not support the hypothesis that serum zinc concentration or dietary zinc intake is associated with the risk of cognitive impairment.

Telehealth Infrastructure, Accountable Care Organization, and Medicare Payment for Patients with Alzheimer's Disease and Related Dementia Living in Socially Vulnerable Areas

Background: Structural social determinants of health have an accumulated negative impact on physical and mental health. Evidence is needed to understand whether emerging health information technology and innovative payment models can help address such structural social determinants for patients with complex health needs, such as Alzheimer's disease and related dementias (ADRD). Objective: This study aimed to test whether telehealth for care coordination and Accountable Care Organization (ACO) enrollment for residents in the most disadvantaged areas, particularly those with ADRD, was associated with reduced Medicare payment. Methods: The study used the merged data set of 2020 Centers for Medicare and Medicaid Services Medicare inpatient claims data, the Medicare Beneficiary Summary File, the Medicare Shared Savings Program ACO, the Center for Medicare and Medicaid Service's Social Vulnerability Index (SVI), and the American Hospital Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries aged 65 years and up. Cross-sectional analyses and generalized linear models (GLM) were implemented. Analyses were implemented from November 2023 to February 2024. Results: Medicare fee-for-service beneficiaries residing in SVI Q4 (i.e., the most vulnerable areas) reported significantly higher total Medicare costs and were least likely to be treated in hospitals that provided telehealth post-discharge services or have ACO affiliation. Meanwhile, the proportion of the population with ADRD was the highest in SVI Q4 compared with other SVI levels. The GLM regression results showed that hospital telehealth post-discharge infrastructure, patient ACO affiliation, SVI Q4, and ADRD were significantly associated with higher Medicare payments. However, coefficients of interaction terms among these factors were significantly negative. For example, the average interaction effect of telehealth post-discharge and ACO, SVI Q4, and ADRD on Medicare payment was -$1,766.2 (95% confidence interval: -$2,576.4 to -$976). Conclusions: Our results suggested that the combination of telehealth post-discharge and ACO financial incentives that promote care coordination is promising to reduce the Medicare cost burden among patients with ADRD living in socially vulnerable areas.

A Genome-Wide Interaction Study of Erythrocyte ω-3 Polyunsaturated Fatty Acid Species and Memory in the Framingham Heart Study Offspring Cohort

BACKGROUND

Cognitive decline, and more specifically Alzheimer's disease, continues to increase in prevalence globally, with few, if any, adequate preventative approaches. Several tests of cognition are utilized in the diagnosis of cognitive decline that assess executive function, short- and long-term memory, cognitive flexibility, and speech and motor control. Recent studies have separately investigated the genetic component of both cognitive health, using these measures, and circulating fatty acids.

OBJECTIVES

We aimed to examine the potential moderating effect of main species of ω-3 polyunsaturated fatty acids (PUFAs) on an individual's genetically conferred risk of cognitive decline.

METHODS

The Offspring cohort from the Framingham Heart Study was cross-sectionally analyzed in this genome-wide interaction study (GWIS). Our sample included all individuals with red blood cell ω-3 PUFA, genetic, cognitive testing (via Trail Making Tests [TMTs]), and covariate data (N = 1620). We used linear mixed effects models to predict each of the 3 cognitive measures (TMT A, TMT B, and TMT D) by each ω-3 PUFA, single nucleotide polymorphism (SNP) (0, 1, or 2 minor alleles), ω-3 PUFA by SNP interaction term, and adjusting for sex, age, education, APOE ε4 genotype status, and kinship (relatedness).

RESULTS

Our analysis identified 31 unique SNPs from 24 genes reaching an exploratory significance threshold of 1×10-5. Fourteen of the 24 genes have been previously associated with the brain/cognition, and 5 genes have been previously associated with circulating lipids. Importantly, 8 of the genes we identified, DAB1, SORCS2, SERINC5, OSBPL3, CPA6, DLG2, MUC19, and RGMA, have been associated with both cognition and circulating lipids. We identified 22 unique SNPs for which individuals with the minor alleles benefit substantially from increased ω-3 fatty acid concentrations and 9 unique SNPs for which the common homozygote benefits.

CONCLUSIONS

In this GWIS of ω-3 PUFA species on cognitive outcomes, we identified 8 unique genes with plausible biology suggesting individuals with specific polymorphisms may have greater potential to benefit from increased ω-3 PUFA intake. Additional replication in prospective settings with more diverse samples is needed.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

Exposure to neighborhood violence, and laboratory-based and ambulatory cognitive task performance in adulthood

OBJECTIVE

Exposure to neighborhood violence may have negative implications for adults' cognitive functioning, but the ecological sensitivity of these effects has yet to be determined. We first evaluated the link between exposure to neighborhood violence and two latent constructs of cognitive function that incorporated laboratory-based and ambulatory, smartphone-based, cognitive assessments. Second, we examined whether the effect of exposure to violence was stronger for ambulatory assessments compared to in-lab assessments.

METHODS

We used data from 256 urban-dwelling adults between 25 and 65 years old (M = 46.26, SD = 11.07); 63.18% non-Hispanic Black, 9.21% non-Hispanic White, 18.41% Hispanic White, 5.02% Hispanic Black, and 4.18% other. Participants completed baseline surveys on neighborhood exposures, cognitive assessments in a laboratory/research office, and ambulatory smartphone-based cognitive assessments five-times a day for 14 days.

RESULTS

Exposure to neighborhood violence was associated with poorer performance in a latent working memory construct that incorporated in-lab and ambulatory assessments, but was not associated with the perceptual speed construct. The effect of exposure to neighborhood violence on the working memory construct was explained by its effect on the ambulatory working memory task and not by the in-lab cognitive assessments.

CONCLUSION

This study shows the negative effect that exposure to neighborhood violence may have on everyday working memory performance in urban-dwelling adults in midlife. Results highlight the need for more research to determine the sensitivity of ambulatory assessments to quantify the effects of neighborhood violence on cognitive function.

Developing Social Enhancements for a Web-Based, Positive Emotion Intervention for Alzheimer Disease Caregivers: Qualitative Focus Group and Interview Study

BACKGROUND

Alzheimer disease is a degenerative neurological condition that requires long-term care. The cost of these responsibilities is often borne by informal caregivers, who experience an elevated risk of negative physical and psychological outcomes. Previously, we designed a positive emotion regulation intervention that was shown to improve well-being among dementia caregivers when delivered through one-on-one videoconferencing lessons with a trained facilitator. However, the format required significant resources in terms of logistics and facilitator time. To broaden the reach of the intervention, we aimed to develop the Social Augmentation of Self-Guided Electronic Delivery of the Life Enhancing Activities for Family Caregivers (SAGE LEAF) program, an iteration of the intervention in a self-guided, web-based format with enhanced opportunities for social connection.

OBJECTIVE

The aim of this study was to gather feedback to inform the design of social features for the SAGE LEAF intervention. In the absence of a facilitator, our goal with the self-guided SAGE LEAF intervention was to integrate various social features (eg, discussion board, automated support, and profiles) to maximize engagement among participants.

METHODS

Qualitative data were collected from 26 individuals through (1) interviews with participants who completed a previous version of the intervention via videoconferencing with a facilitator, (2) focus groups with dementia caregivers who had not previously experienced the intervention, and (3) focus groups with Alzheimer disease clinical care providers. We conducted a qualitative thematic analysis to identify which social features would be the most helpful and how they could be implemented in a way that would be best received by caregivers.

RESULTS

Interview and focus group feedback indicated that participants generally liked the potential features suggested, including the discussion boards, multimedia content, and informational support. They had valuable suggestions for optimal implementation. For example, participants liked the idea of a buddy system where they would be matched up with another caregiver for the duration of the study. However, they expressed concern about differing expectations among caregivers and the possibility of matched caregivers not getting along. Participants also expressed interest in giving caregivers access to a podcast on the skills, which would allow them to review additional content when they wished.

CONCLUSIONS

Taken together, the discussions with caregivers and providers offered unique insights into the types of social features that may be integrated into the SAGE LEAF intervention, as well as implementation suggestions to improve the acceptability of the features among caregivers. These insights will allow us to design social features for the intervention that are optimally engaging and helpful for caregivers.

Interventions to Foster Resilience in Family Caregivers of People with Alzheimer's Disease: A Scoping Review

The family caregiver of a person with Alzheimer's disease still experiences, in most cases, negative consequences in their biopsychosocial environment, which are related to the acquisition of this role. However, it has been observed that this fact is not universal in this type of population since benefits can be obtained in the act of caring through the development of resilience. Given this possibility and given that nurses are the health professionals who support people in this illness process, there is an urgent need to identify which non-pharmacological interventions could improve or promote resilience in family caregivers of people with Alzheimer's disease. Therefore, our overall objective was to determine which interventions are useful in promoting resilience in family caregivers of people with Alzheimer's disease through a scoping review. The data were analysed using an adapted version of Arksey and O'Malley's methodological framework, after critically reading the articles with the CasP and MMAT tools. Nine articles were included (five analytical experimental, two quantitative and two mixed). Three types of interventions related to promoting resilience in family caregivers of people with Alzheimer's disease were identified: meditation, multicomponent psychoeducation and creative art; nurses participated as co-therapists in the last two.

Platelet Dynamics in Neurodegenerative Disorders: Investigating the Role of Platelets in Neurological Pathology

Background: Neurological disorders, particularly those associated with aging, pose significant challenges in early diagnosis and treatment. The identification of specific biomarkers, such as platelets (PLTs), has emerged as a promising strategy for early detection and intervention in neurological health. This systematic review aims to explore the intricate relationship between PLT dynamics and neurological health, focusing on their potential role in cognitive functions and the pathogenesis of cognitive disorders. Methods: Adhering to PRISMA guidelines, a comprehensive search strategy was employed in the PubMed and Scholar databases to identify studies on the role of PLTs in neurological disorders published from 2013 to 2023. The search criteria included studies focusing on PLTs as biomarkers in neurological disorders, their dynamics, and their potential in monitoring disease progression and therapy effectiveness. Results: The systematic review included 104 studies, revealing PLTs as crucial biomarkers in neurocognitive disorders, acting as inflammatory mediators. The findings suggest that PLTs share common features with altered neurons, which could be utilised for monitoring disease progression and evaluating the effectiveness of treatments. PLTs are identified as significant biomarkers for detecting neurological disorders in their early stages and understanding the pathological events leading to neuronal death. Conclusions: The systematic review underscores the critical role of PLTs in neurological disorders, highlighting their potential as biomarkers for the early detection and monitoring of disease progression. However, it also emphasises the need for further research to solidify the use of PLTs in neurological disorders, aiming to enhance early diagnosis and intervention strategies.

Smart home automation technology to support caring of individuals with Alzheimer's disease and related dementia: an early intervention framework

PURPOSE

Home automation technology comprising of Internet of Things and Smart gadgets is a rapidly growing industry that is projected to have a major scope for ageing-in-place and caregiving. This study examined the feasibility and cost-benefits of a personalized home automation intervention for care of individuals with Alzheimer's disease and related dementia (ADRD) with emphasis on their safety and independence, and reduction of care burden.

METHODS

A mixed method intervention study was conducted with five dyads each comprising of a caregiver and care recipient with ADRD. Each dyad received personalized home automation intervention with individualized goals centred on home safety, activity engagement, and caregiver-recipient connectivity. The goals were created and monitored using goal attainment scaling (GAS). The dyads were followed up after three months with a home visit and interview. Goal attainment scoring and thematic analysis of the interviews were conducted to examine the findings from the study.

RESULTS

All dyads indicated positive goal attainment between pre and post intervention. Goals that were met were complimented by the categories of peace of mind, self-efficacy, and care recipient engagement, while unmet goals as well as complexities with the technology were elucidated under challenges. Overarching and conceptually linked themes from the study were unfamiliarity, value, and timing.

CONCLUSION

Home automation technology has the potential to be adapted to promote independence and safety of individuals with ADRD while relieving care burden. Nonetheless, we propose an early intervention framework to overcome identified challenges and optimize the technology's usability and sustainability.IMPLICATIONS FOR REHABILITATIONHome automation involving Internet of Things and Smart gadgets has gained rapid popularity owing to the comfort and connectivity they provide to mainstream consumers.The technology has an emerging significance to ageing-in-place and care of individuals with Alzheimer's Disease and Related Dementia (ADRD) as it can be adapted and implemented to enhance home safety and activity engagement of the care recipients while also strengthening their connectivity with the caregivers.Unfamiliarity with the technology compounded by the progression of ADRD can, however, be detrimental to its adoption.Individualized focus and early integration of the technology for caregiver-care recipient dyads can mitigate these challenges and optimize its usability and long-term value in relation to ageing-in-place and caregiver wellbeing.

Differential DNA methylation in the brain as potential mediator of the association between traffic-related PM2.5 and neuropathology markers of Alzheimer's disease

INTRODUCTION

Growing evidence indicates that fine particulate matter (PM2.5) is a risk factor for Alzheimer's disease (AD), but the underlying mechanisms have been insufficiently investigated. We hypothesized differential DNA methylation (DNAm) in brain tissue as a potential mediator of this association.

METHODS

We assessed genome-wide DNAm (Illumina EPIC BeadChips) in prefrontal cortex tissue and three AD-related neuropathological markers (Braak stage, CERAD, ABC score) for 159 donors, and estimated donors' residential traffic-related PM2.5 exposure 1, 3, and 5 years prior to death. We used a combination of the Meet-in-the-Middle approach, high-dimensional mediation analysis, and causal mediation analysis to identify potential mediating CpGs.

RESULTS

PM2.5 was significantly associated with differential DNAm at cg25433380 and cg10495669. Twenty-four CpG sites were identified as mediators of the association between PM2.5 exposure and neuropathology markers, several located in genes related to neuroinflammation.

DISCUSSION

Our findings suggest differential DNAm related to neuroinflammation mediates the association between traffic-related PM2.5 and AD.

HIGHLIGHTS

First study to evaluate the potential mediation effect of DNA methylation for the association between PM2.5 exposure and neuropathological changes of Alzheimer's disease. Study was based on brain tissues rarely investigated in previous air pollution research. Cg10495669, assigned to RBCK1 gene playing a role in inflammation, was associated consistently with 1-year, 3-year, and 5-year traffic-related PM2.5 exposures prior to death. Meet-in-the-middle approach and high-dimensional mediation analysis were used simultaneously to increase the potential of identifying the differentially methylated CpGs. Differential DNAm related to neuroinflammation was found to mediate the association between traffic-related PM2.5 and Alzheimer's disease.

Home time and state regulations among Medicare beneficiaries in assisted living communities

BACKGROUND

Home time is an important patient-centric quality metric, which has been largely unexamined among assisted living (AL) residents. Our objectives were to assess variation in home time among AL residents in the year following admission and to examine the associations with state regulations for direct care workers (DCW) training and staffing and for licensed nurse staffing.

METHODS

Medicare beneficiaries who entered AL communities in 2018 were identified, and their home time in the year following admission was measured. Home time was calculated as the percentage of time spent at home per day being alive. Resident characteristics and state regulations in DCW staffing, DCW training, and licensed staffing were measured. We used a multivariate linear regression model with AL-level fixed effects to estimate the relationship between person-level characteristics and home time. Linear regression models adjusting for resident characteristics were used to estimate the association between state regulations and residents' home time.

RESULTS

The study sample included 59,831 new Medicare beneficiary residents in 12,143 ALs. In the year following AL admission, residents spent 94% (standard deviation = 14.6) of their time at home. Several resident characteristics were associated with lower home time: Medicare-Medicaid dual eligibility, having more chronic conditions, and specific chronic conditions, for example, dementia. In states with greater regulatory specificity for DCW training and staffing, and lower specificity for licensed staffing, residents had longer adjusted home time.

CONCLUSION/IMPLICATIONS

Home time varied substantially among AL residents depending on resident characteristics and state-level regulatory specificity. AL residents eligible for Medicare and Medicaid had substantially shorter home time than the Medicare-only residents, largely due to longer time spent in nursing homes. State AL regulatory specificity for DCWs and licensed staff also impacted AL residents' home time. These findings may guide AL operators and state legislators in efforts to improve this important quality of life metric.

Cost of care for Alzheimer's disease and related dementias in the United States: 2016 to 2060

Medical and long-term care for Alzheimer's disease and related dementias (ADRDs) can impose a large economic burden on individuals and societies. We estimated the per capita cost of ADRDs care in the in the United States in 2016 and projected future aggregate care costs during 2020-2060. Based on a previously published methodology, we used U.S. Health and Retirement Survey (2010-2016) longitudinal data to estimate formal and informal care costs. In 2016, the estimated per patient cost of formal care was $28,078 (95% confidence interval [CI]: $25,893-$30,433), and informal care cost valued in terms of replacement cost and forgone wages was $36,667 ($34,025-$39,473) and $15,792 ($12,980-$18,713), respectively. Aggregate formal care cost and formal plus informal care cost using replacement cost and forgone wage methods were $196 billion (95% uncertainty range [UR]: $179-$213 billion), $450 billion ($424-$478 billion), and $305 billion ($278-$333 billion), respectively, in 2020. These were projected to increase to $1.4 trillion ($837 billion-$2.2 trillion), $3.3 trillion ($1.9-$5.1 trillion), and $2.2 trillion ($1.3-$3.5 trillion), respectively, in 2060.

Comorbid Conditions Are Associated With Cognitive Impairment in Native Hawaiians and Pacific Islanders

We examined the association between comorbid conditions and mild cognitive impairment (MCI) in Native Hawaiians and Pacific Islanders (NHPI) (n = 54). Cross-sectional, self-reported questionnaires were utilized to collect demographic, comorbid conditions, and MCI (via the AD8 index) data. Separate logistic regression models were conducted to investigate the relationship between comorbid conditions and MCI, adjusting for other covariates. We found significantly increased odds of MCI in those reporting high blood pressure (OR = 5.27; 95% CI: [1.36, 20.46]; p = 0.016), high cholesterol (OR = 7.30; 95% CI: [1.90, 28.14], p = 0.004), and prediabetes or borderline diabetes (OR = 4.53; 95% CI: [1.27, 16.16], p = 0.02) compared with those not reporting these respective conditions. These data show that hypertension, hypercholesterolemia, and prediabetes are associated with MCI in the NHPI community, suggesting that preventive strategies to reduce chronic conditions may also potentially slow cognitive decline in underrepresented/understudied NHPI.

Impact of dance interventions on the symptoms of dementia: A mixed-methods systematic review

OBJECTIVES

This mixed-methods systematic review determined the impact of dance interventions on symptoms of Alzheimer's disease and related dementias (ADRD) among persons living in residential care.

METHODS

Seven databases (Medline, EMBASE, CINAHL, PsycINFO, Web of Science, Ageline, and AMED) were searched. Studies published before June 2022 that investigated the impact of dance interventions on symptoms of ADRD were eligible for inclusion. Risk of bias was assessed using CASP, ROBINS-I, and ROB-2. Quantitative and qualitative objectives provided a convergent segregate narrative synthesis for the review. The review protocol was registered on PROSPERO (CRD42021220535).

RESULTS

Two quantitative and two qualitative studies met the inclusion criteria. Dance interventions decreased levels of agitation and aggression, and improved behavioural and psychological symptoms.

CONCLUSIONS

Studies suggest that dance interventions reduce the symptoms of dementia through increased expression, emotions, and improved relationships for persons with ADRD. However, the small number of included studies limits these conclusions.

Out-of-Pocket Expenses for Long-Term Care by Dementia Status and Residential Setting among US Older Adults

OBJECTIVE

To examine long-term care out-of-pocket payments by dementia status and residential setting.

DESIGN

Compare monthly out-of-pocket long-term care expenses paid to facilities and helpers, total monthly out-of-pocket long-term expenses and as a percentage of monthly income by dementia status and residential status (community, residential facility, and nursing home).

SETTING AND PARTICIPANTS

US Nationwide, 2019 National Health and Aging Trends Study (NHATS) respondents aged ≥70 years.

METHODS

We analyzed respondent-level data from the nationally representative 2019 NHATS. Weighted descriptive statistics were calculated for long-term care payments by source and summarized by dementia status and the respondent's residential status.

RESULTS

Among 4505 respondents aged ≥70 years, 1750 (38.8%) had possible or probable dementia and 2755 (61.2%) had no dementia. The median monthly out-of-pocket long-term care expenses for persons with dementia was $1465 for those living in nursing homes, and $2925 for those living in other residential facilities, much higher than those with dementia living in the community ($260). Although these are similar to the median out-of-pocket payments for persons without dementia by setting, those with dementia were at greater risk of facing catastrophic out-of-pocket expenses for long-term care than those without dementia, with the 75th percentile value of out-of-pocket payment at $4566 among dementia adults living in non-nursing home residential care facilities, and $7500 for those in nursing homes, compared to $3694 and $3100 among those without dementia. At median, these expenses accounted for 100% of monthly income of respondents with dementia living in facilities.

CONCLUSIONS AND IMPLICATIONS

Persons with dementia living in facilities often face substantial financial burdens from high out-of-pocket long-term care expenses. Policies that provide sufficient financial assistance are needed to address long-term care-related financial burdens experienced by older adults and their families, especially for those with dementia.

Assessing Quality of Life, Economic Burden, and Independence Across the Alzheimer's Disease Continuum Using Patient-Caregiver Dyad Surveys

Background

Alzheimer's disease (AD) and mild cognitive impairment (MCI) have negative quality of life (QoL) and economic impacts on patients and their caregivers and may increase along the disease continuum from MCI to mild, moderate, and severe AD.

Objective

To assess how patient and caregiver QoL, indirect and intangible costs are associated with MCI and AD severity.

Methods

An on-line survey of physician-identified patient-caregiver dyads living in the United States was conducted from June-October 2022 and included questions to both patients and their caregivers. Dementia Quality of Life Proxy, the Care-related Quality of Life, Work Productivity and Activity Impairment, and Dependence scale were incorporated into the survey. Regression analyses investigated the association between disease severity and QoL and cost outcomes with adjustment for baseline characteristics.

Results

One-hundred patient-caregiver dyads were assessed with the survey (MCI, n = 27; mild AD, n = 27; moderate AD, n = 25; severe AD, n = 21). Decreased QoL was found with worsening severity in patients (p < 0.01) and in unpaid (informal) caregivers (n = 79; p = 0.02). Dependence increased with disease severity (p < 0.01). Advanced disease severity was associated with higher costs to employers (p = 0.04), but not with indirect costs to caregivers. Patient and unpaid caregiver intangible costs increased with disease severity (p < 0.01). A significant trend of higher summed costs (indirect costs to caregivers, costs to employers, intangible costs to patients and caregivers) in more severe AD was observed (p < 0.01).

Conclusions

Patient QoL and functional independence and unpaid caregiver QoL decrease as AD severity increases. Intangible costs to patients and summed costs increase with disease severity and are highest in severe AD.

Incremental burden on health-related quality of life, health service utilization and direct medical expenditures associated with cognitive impairment among non-institutionalized people with diabetes aged 65 years and older

AIMS

To quantify the incremental health and economic burden associated with cognitive impairment (CI) among non-institutionalized people with diabetes ≥65 years in the United States.

MATERIALS AND METHODS

Using 2016-2019 Medical Expenditure Panel Surveys data, we identified participants ≥65 years with diabetes. We used propensity score weighting to quantify the CI-associated incremental burden on health-related quality of life measured by the 12-item Short Form Survey (SF-12), including the mental component summary score, physical component summary score and health utility. We also compared the annual health service utilization and expenditures on ambulatory visits, prescriptions, home care, emergency room (ER), hospitalizations and total annual direct medical expenditures.

RESULTS

We included 5094 adults aged ≥65 with diabetes, of whom 804 had CI. After propensity score weighting, CI was associated with a lower mental component summary score (-8.4, p < .001), physical component summary score (-5.2, p < .001) and health utility (-0.12, p < .001). The CI group had more ambulatory visits (+4.4, p = .004) and prescriptions (+9.9, p < .001), with higher probabilities of having home care (+11.3%, p < .001) and ER visits (+8.2%, p = .001). People with CI spent $5441 (p < .001) more annually, $2039 (p = .002) more on prescriptions, $2695 (p < .001) more on home care and $118 (p < .001) more on ER visits. There is no statistically significant difference in the utilization and expenditure of hospitalizations.

CONCLUSION

CI was associated with worse health-related quality of life, higher health service utilization and expenditures. Our findings can be used to monitor the health and economic burden of CI in non-institutionalized older persons with diabetes.

Association between perceived risk of Alzheimer's disease and related dementias and cognitive function among U.S. older adults

INTRODUCTION

The aim of the study was to assess factors associated with the perceived risk of developing Alzheimer's disease and related dementias (ADRD) and how the perceived risk of ADRD was related to cognitive function.

METHODS

We conducted a retrospective cohort study using 5 waves of data from the Health and Retirement Study (2012-2022) that included adults aged 65 years or older with no previous diagnosis of ADRD at baseline. Cognitive function was measured at baseline and over time using a summary score that included immediate/delayed word recall, serial 7's test, objective naming test, backwards counting, recall of the current date, and naming the president/vice-president (range = 0-35). Perceived risk of developing ADRD was categorized at baseline as "definitely not" (0% probability), "unlikely" (1-49%), "uncertain" (50%), and "more than likely" (>50-100%). Additional baseline measures included participants' sociodemographic background, psychosocial resources, health behaviors, physiological status, and healthcare utilization.

RESULTS

Of 1457 respondents (median age 74 [IQR = 69-80] and 59.8% women), individuals who perceived that they were "more than likely" to develop ADRD had more depressive symptoms and were more likely to be hospitalized in the past two years than individuals who indicated that it was "unlikely" they would develop ADRD. Alternatively, respondnets who perceived that they would "definitely not" develop ADRD were more likely to be non-Hispanic Black, less educated, and have lower income than individuals who indicated it was "unlikely" they would develop ADRD. Respondents who reported their risks of developing ADRD as "more than likely" (β = -2.10, P < 0.001) and "definitely not" (β = -1.50, P < 0.001) had the lowest levels of cognitive function; and the associations were explained in part by their socioeconomic, psychosocial, and health status.

CONCLUSIONS

Perceived risk of developing ADRD is associated with cognitive function. The (dis)concordance between individuals' perceived risk of ADRD and their cognitive function has important implications for increasing public awareness and developing interventions to prevent ADRD.

The intersection of social determinants of health and family care of people living with Alzheimer's disease and related dementias: A public health opportunity

In this Perspective article, we highlight current research to illustrate the intersection of social determinants of health (SDOHs) and Alzheimer's disease and related dementia (ADRD) caregiving. We then outline how public health can support ADRD family caregivers in the United States. Emerging research suggests that family care for persons with ADRD is influenced by SDOHs. Public health actions that address these intersections such as improved surveillance and identification of ADRD caregivers; building and enhancing community partnerships; advancing dementia-capable health care and related payment incentives; and reducing the stigma of dementia and ADRD caregiving can potentially enhance the health and well-being of dementia caregivers. By engaging in one or all of these actions, public health practitioners could more effectively address the myriad of challenges facing ADRD caregivers most at risk for emotional, social, financial, psychological, and health disruption.

Balance-based exercise programs on balance in older adults with mild to moderate dementia: A critically appraised topic

OBJECTIVE

It is well established that exercise programs including balanced-based exercises are practical and beneficial for cognitively healthy older adults. However, there is limited evidence to determine if these types of training regimens are effective for individuals with dementia. We conducted a critical appraisal to determine if the addition of balance-based exercise programs, compared with usual care at residential homes, improved balance in adults diagnosed with mild to moderate dementia.

MATERIALS AND METHODS

Four databases were searched for randomized control trials implementing balanced-based exercise programs with individuals diagnosed with mild to moderate dementia. The articles were evaluated based on the Centre for Evidence Based Medicine level of evidence criteria and appraised using the PEDro scale.

RESULTS

A comprehensive literature search revealed four studies relevant to the clinical question that fit the inclusion and exclusion criteria. All four studies indicated an improvement in balance following a weekly physical therapy program implementing balance-based exercises.

CONCLUSIONS

There is sufficient evidence to suggest that the use of physical therapy programs that include balance-based exercises, performed 1-2 times a week over the course of 12-25 weeks, improves balance in elderly adults with mild to moderate dementia.

Cognitive status and its risk factors in patients with hypertension and diabetes in a low-income rural area of China: A cross-sectional study

OBJECTIVES

The proportion of older people with dementia in China is gradually increasing with the increase in the aging population over recent years. Hypertension and diabetes are common non-communicable diseases among rural populations in China. However, it remains unclear whether these conditions affect the occurrence and development of cognitive impairment as there is limited research on cognitive status and its risk factors among residents of rural areas.

METHODS

A multi-stage stratified cluster random sampling method was used to select 5400 participants from rural permanent residents. A self-designed structured questionnaire was used to investigate demographic data of the participants. Cognitive function was assessed using the Montreal Cognitive Function Assessment Scale (MoCA). The results were analyzed using chi-square test, ANOVA and multiple linear regression analysis.

RESULTS

A total of 5028 participants returned the survey, giving a response rate of 93.1%. Higher education (odds ratio (OR) = 3.2, 95% confidence interval (CI) 2.87-3.54, p < 0.001), higher income (OR = 1.61, 95% CI 1.16-2.07, p < 0.001), and dietary control (OR = 0.66, 95%CI 0.34-0.98, p < 0.001) were protective factors. A visual representation of the relationship between annual income and MoCA score showed an inverted U-curve, the group with an annual income of 6000-7999 RMB had a maximum OR of 1.93 (95%CI 0.12-2.74, p < 0.001). While difficulty in maintaining sleep were risk factors for cognitive impairment (OR = -2.28, 95% CI-4.18-0.39, p = 0.018).

CONCLUSIONS

Participants with middle incomes had better cognitive status than those with the highest incomes. Higher education, proper diet control and good sleep are beneficial to the cognitive status of residents in rural areas.

The national public health response to Alzheimer's disease and related dementias: Origins, evolution, and recommendations to improve early detection

Longstanding gaps in the detection of Alzheimer's disease and related dementias (ADRD) and biopsychosocial care call for public health action to improve population health. We aim to broaden the understanding of the iterative role state plans have played over the last 20 years in prioritizing improvements in the detection of ADRD, primary care capacity, and equity for disproportionately affected populations. Informed by national ADRD priorities, state plans convene stakeholders to identify local needs, gaps, and barriers and set the stage for development of a national public health infrastructure that can align clinical practice reform with population health goals. We propose policy and practice actions that would accelerate the collaboration between public health, community organizations, and health systems to improve ADRD detection-the point of entry into care pathways that could ultimately improve outcomes on a national scale. HIGHLIGHTS: We systematically reviewed the evolution of state/territory plans for Alzheimer's disease and related dementias (ADRD). Plan goals improved over time but lacked implementation capacity. Landmark federal legislation (2018) enabled funding for action and accountability. The Centers for Disease Control and Prevention (CDC) funds three Public Health Centers of Excellence and many local initiatives. Four new policy steps would promote sustainable ADRD population health improvement.

HomeADScreen: Developing Alzheimer's disease and related dementia risk identification model in home healthcare

BACKGROUND

More than 50 % of patients with Alzheimer's disease and related dementia (ADRD) remain undiagnosed. This is specifically the case for home healthcare (HHC) patients.

OBJECTIVES

This study aimed at developing HomeADScreen, an ADRD risk screening model built on the combination of HHC patients' structured data and information extracted from HHC clinical notes.

METHODS

The study's sample included 15,973 HHC patients with no diagnosis of ADRD and 8,901 patients diagnosed with ADRD across four follow-up time windows. First, we applied two natural language processing methods, Word2Vec and topic modeling methods, to extract ADRD risk factors from clinical notes. Next, we built the risk identification model on the combination of the Outcome and Assessment Information Set (OASIS-structured data collected in the HHC setting) and clinical notes-risk factors across the four-time windows.

RESULTS

The top-performing machine learning algorithm attained an Area under the Curve = 0.76 for a four-year risk prediction time window. After optimizing the cut-off value for screening patients with ADRD (cut-off-value = 0.31), we achieved sensitivity = 0.75 and an F1-score = 0.63. For the first-year time window, adding clinical note-derived risk factors to OASIS data improved the overall performance of the risk identification model by 60 %. We observed a similar trend of increasing the model's overall performance across other time windows. Variables associated with increased risk of ADRD were "hearing impairment" and "impaired patient ability in the use of telephone." On the other hand, being "non-Hispanic White" and the "absence of impairment with prior daily functioning" were associated with a lower risk of ADRD.

CONCLUSION

HomeADScreen has a strong potential to be translated into clinical practice and assist HHC clinicians in assessing patients' cognitive function and referring them for further neurological assessment.

Exploring the relationship between patient-relevant outcomes and Alzheimer's disease progression assessed using the clinical dementia rating scale: a systematic literature review

Background

People with Alzheimer's disease (AD) have difficulties in performing activities of daily living (ADLs) as the disease progresses, commonly experience neuropsychiatric symptoms (NPS), and often have comorbidities such as cardiovascular disease. These factors all contribute to a requirement for care and considerable healthcare costs in AD. The Clinical Dementia Rating (CDR) scale is a widely used measure of dementia staging, but the correlations between scores on this scale and patient-/care partner-relevant outcomes have not been characterized fully. We conducted a systematic literature review to address this evidence gap.

Methods

Embase, MEDLINE, and the Cochrane Library were searched September 13, 2022, to identify published studies (no restriction by date or country) in populations with mild cognitive impairment due to AD or AD dementia. Studies of interest reported data on the relationships between CDR Global or CDR-Sum of Boxes (CDR-SB) scores and outcomes including NPS, comorbidities, ADLs, nursing home placement, healthcare costs, and resource use.

Results

Overall, 58 studies met the inclusion criteria (42 focusing on comorbidities, 14 on ADLs or dependence, five on nursing home placement, and six on economic outcomes). CDR/CDR-SB scores were correlated with the frequency of multiple NPS and with total scores on the Neuropsychiatric Inventory. For cardiovascular comorbidities, no single risk factor was consistently linked to AD progression. Increasing CDR/CDR-SB scores were correlated with decline in multiple different measures of ADLs and were also associated with nursing home placement and increasing costs of care.

Conclusion

NPS, ADLs, and costs of care are clearly linked to AD progression, as measured using CDR Global or CDR-SB scores, from the earliest stages of disease. This indicates that scores derived from the CDR are a meaningful way to describe the severity and burden of AD for patients and care partners across disease stages.

Differential DNA Methylation in the Brain as Potential Mediator of the Association between Traffic-related PM2.5 and Neuropathology Markers of Alzheimer's Disease

INTRODUCTION

Growing evidence indicates fine particulate matter (PM2.5) as risk factor for Alzheimer's' disease (AD), but the underlying mechanisms have been insufficiently investigated. We hypothesized differential DNA methylation (DNAm) in brain tissue as potential mediator of this association.

METHODS

We assessed genome-wide DNAm (Illumina EPIC BeadChips) in prefrontal cortex tissue and three AD-related neuropathological markers (Braak stage, CERAD, ABC score) for 159 donors, and estimated donors' residential traffic-related PM2.5 exposure 1, 3 and 5 years prior to death. We used a combination of the Meet-in-the-Middle approach, high-dimensional mediation analysis, and causal mediation analysis to identify potential mediating CpGs.

RESULTS

PM2.5 was significantly associated with differential DNAm at cg25433380 and cg10495669. Twenty-six CpG sites were identified as mediators of the association between PM2.5 exposure and neuropathology markers, several located in genes related to neuroinflammation.

DISCUSSION

Our findings suggest differential DNAm related to neuroinflammation mediates the association between traffic-related PM2.5 and AD.

Self-rated health as a predictor of cognition among middle-aged and older Latinos

Self-rated health (SRH) has been used to predict cognitive decline in various populations; however, this relationship has not been examined in Latinos. This study examines the relationship between SRH and cognition among middle-aged and older Latinos. A cross-sectional analysis was conducted among Latinos (n = 425, Mage = 64.13 ± 7.65, 82% female). Participants rated their health as poor/fair, good, and excellent and completed cognitive performance tests. Analyses of covariance (ANCOVA) examined differences in cognition between SRH categories. ANCOVAs showed significant differences in SRH categories for working memory (F [2, 357] = 3.63, p = .028) and global cognition (F [2, 348] = 3.074, p = .047), such that those who self-rated their health as good had better scores compared to participants in the poor/fair category. Findings show that SRH is associated with cognition among middle-aged and older Latinos. SRH may serve as an indicator of early signs of cognitive decline.

One-year Medicare costs associated with delirium in older hospitalized patients with and without Alzheimer's disease dementia and related disorders

INTRODUCTION

One-year health-care costs associated with delirium in older hospitalized patients with and without Alzheimer's disease and related dementias (ADRD) have not been examined previously.

METHODS

Medicare costs were determined prospectively at discharge, and at 30, 90, and 365 days in a cohort (n = 311) of older adults after hospital admission.

RESULTS

Seventy-six (24%) patients had ADRD and were more likely to develop delirium (51% vs. 24%, P < 0.001) and die within 1 year (38% vs. 21%, P = 0.002). In ADRD patients with versus without delirium, adjusted mean difference in costs associated with delirium were $34,828; most of the excess costs were incurred between 90 and 365 days (P = 0.03). In non-ADRD patients, delirium was associated with increased costs at all timepoints. Excess costs associated with delirium in ADRD patients increased progressively over 1 year, whereas in non-ADRD patients the increase was consistent across time periods.

DISCUSSION

Our findings highlight the complexity of health-care costs for ADRD patients who develop delirium, a potentially preventable source of expenditures.

HIGHLIGHTS

Novel examination of health-care costs of delirium in persons with and without Alzheimer's disease and related dementias (ADRD). Increased 1-year costs of $34,828 in ADRD patients with delirium (vs. without). Increased costs for delirium in ADRD occur later during the 365-day study period. For ADRD patients, cost differences between those with and without delirium increased over 1 year. For non-ADRD patients, the parallel cost differences were consistent over time.

Meaningful Clinical Changes in Alzheimer Disease Measured With the iADRS and Illustrated Using the Donanemab TRAILBLAZER-ALZ Study Findings

Purpose of Review

To provide relevant background of the Integrated Alzheimer's Disease Rating Scale (iADRS), with examples, to assist the reader with the interpretation of iADRS findings from the TRAILBLAZER-ALZ study.

Recent Findings

The iADRS is an integrated measure of global Alzheimer disease (AD) severity for use in the clinical trial environment. It provides a single score that captures commonalities across cognitive and functional ability domains, reflecting disease-related impairment, while minimizing noise not related to disease progression that may exist within each domain. In AD, disease-modifying therapies (DMTs) are expected to slow the rate of clinical decline, changing the trajectory of disease progression. The overall percent slowing of disease progression with treatment is a more informative outcome of effect than absolute point differences between treatment and placebo groups at any given time point because the latter is influenced by treatment period and disease severity. The TRAILBLAZER-ALZ trial was a phase 2 study designed to evaluate the safety and efficacy of donanemab in participants with early symptomatic AD; the primary outcome measure was the change from baseline to 76 weeks on the iADRS. In the TRAILBLAZER-ALZ study, donanemab slowed disease progression by 32% at 18 months (p = 0.04 vs placebo), demonstrating clinical efficacy. At the patient level, one can assess whether the DMT effect is clinically meaningful by estimating the threshold of change consistent with clinically meaningful worsening; based on the TRAILBLAZER-ALZ findings, treatment with donanemab would delay reaching this threshold by approximately 6 months.

Summary

The iADRS is capable of accurately describing clinical changes associated with disease progression and detecting treatment effects and is an effective assessment tool for use in clinical trials of individuals with early symptomatic AD.

2023 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease, including prevalence and incidence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report examines the patient journey from awareness of cognitive changes to potential treatment with drugs that change the underlying biology of Alzheimer's. An estimated 6.7 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, and Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated by the COVID-19 pandemic in 2020 and 2021. More than 11 million family members and other unpaid caregivers provided an estimated 18 billion hours of care to people with Alzheimer's or other dementias in 2022. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $339.5 billion in 2022. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the paid health care workforce are involved in diagnosing, treating and caring for people with dementia. In recent years, however, a shortage of such workers has developed in the United States. This shortage - brought about, in part, by COVID-19 - has occurred at a time when more members of the dementia care workforce are needed. Therefore, programs will be needed to attract workers and better train health care teams. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2023 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $345 billion. The Special Report examines whether there will be sufficient numbers of physician specialists to provide Alzheimer's care and treatment now that two drugs are available that change the underlying biology of Alzheimer's disease.

Hypoperfusion Precedes Tau Deposition in the Entorhinal Cortex: A Retrospective Evaluation of ADNI-2 Data

BACKGROUND AND PURPOSE

Tau deposition in the entorhinal cortex is the earliest pathological feature of Alzheimer's disease (AD). However, this feature has also been observed in cognitively normal (CN) individuals and those with mild cognitive impairment (MCI). The precise pathophysiology for the development of tau deposition remains unclear. We hypothesized that reduced cerebral perfusion is associated with the development of tau deposition.

METHODS

A subset of the Alzheimer's Disease Neuroimaging Initiative data set was utilized. Included patients had undergone arterial spin labeling perfusion MRI along with [¹⁸F]flortaucipir tau PET at baseline, within 1 year of the MRI, and a follow-up at 6 years. The association between baseline cerebral blood flow (CBF) and the baseline and 6-year tau PET was assessed. Univariate and multivariate linear modeling was performed, with p<0.05 indicating significance.

RESULTS

Significant differences were found in the CBF between patients with AD and MCI, and CN individuals in the left entorhinal cortex (p=0.013), but not in the right entorhinal cortex (p=0.076). The difference in maximum standardized uptake value ratio between 6 years and baseline was significantly and inversely associated with the baseline mean CBF (p=0.042, R²=0.54) in the left entorhinal cortex but not the right entorhinal cortex. Linear modeling demonstrated that CBF predicted 6-year tau deposition (p=0.015, R²=0.11).

CONCLUSIONS

The results of this study suggest that a reduction in CBF at the entorhinal cortex precedes tau deposition. Further work is needed to understand the mechanism underlying tau deposition in aging and disease.

Short-term associations between warm-season ambient temperature and emergency department visits for Alzheimer's disease and related dementia in five US states

BACKGROUND

Ambient temperatures are projected to increase in the future due to climate change. Alzheimer's disease (AD) and Alzheimer's disease-related dementia (ADRD) affect millions of individuals and represent substantial health burdens in the US. High temperature may be a risk factor for AD/ADRD outcomes with several recent studies reporting associations between temperature and AD mortality. However, the link between heat and AD morbidity is poorly understood.

METHODS

We examined short-term associations between warm-season daily ambient temperature and AD/ADRD emergency department (ED) visits for individuals aged 45 years or above during the warm season (May to October) for up to 14 years (2005-2018) in five US states: California, Missouri, North Carolina, New Jersey, and New York. Daily ZIP code-level maximum, average and minimum temperature exposures were derived from 1 km gridded Daymet products. Associations are assessed using a time-stratified case-crossover design using conditional logistic regression.

RESULTS

We found consistent positive short-term effects of ambient temperature among 3.4 million AD/ADRD ED visits across five states. An increase of the 3-day cumulative temperature exposure of daily average temperature from the 50th to the 95th percentile was associated with a pooled odds ratio of 1.042 (95% CI: 1.034, 1.051) for AD/ADRD ED visits. We observed evidence of the association being stronger for patients 65-74 years of age and for ED visits that led to hospital admissions. Temperature associations were also stronger among AD/ADRD ED visits compared to ED visits for other reasons, particularly among patients aged 65-74 years.

CONCLUSION

People with AD/ADRD may represent a vulnerable population affected by short-term exposure to high temperature. Our results support the development of targeted strategies to reduce heat-related AD/ADRD morbidity in the context of global warming.

Dementia's Unique Burden: Function and Health Care in the Last 4 Years of Life

BACKGROUND

Dementia is a terminal illness marked by progressive cognitive decline. This study characterized trajectories of functional status and health care use for people with and without dementia at the end of their life.

METHODS

We used the Health and Retirement Study linked with Medicare claims to generate a series of generalized linear models. Models predicted functional status and health care use for decedents with and without dementia during each month in the last 4 years of life (48 months).

RESULTS

People with dementia have high, sustained functional impairments during the entire last 4 years of life. People with dementia have the same predicted average activities of daily living score (1.92) at 17 months before death (95% confidence interval [CI]: 1.857, 1.989) as individuals without dementia at 6 months before death (95% CI: 1.842, 1.991). Dementia was associated with significantly less hospice during the final 3 months of life, with a 12.5% (95% CI: 11.046, 13.906) likelihood of hospice in the last month of life with dementia versus 17.3% (95% CI: 15.573, 18.982) without dementia. Dementia was also associated with less durable medical equipment (p < .001), less home health care (p < .005), and fewer office visits (p < .001). There were not significant differences in likelihood of hospitalization in the last 48 months with or without dementia.

CONCLUSIONS

People with dementia can functionally appear to be at end of life (EOL) for years before their death. Simultaneously, they receive less health care, particularly home health and hospice, in their last months. Models of care that target people with dementia should consider the unique and sustained burden of dementia at EOL.

The Case for a Novel Therapeutic Approach to Dementia: Small Molecule Hepatocyte Growth Factor (HGF/MET) Positive Modulators

An estimated 6.5 million Americans aged 65 years or older have Alzheimer's disease (AD), which will grow to 13.8 million Americans by 2060. Despite the growing burden of dementia, no fundamental change in drug development for AD has been seen in > 20 years. Currently approved drugs for AD produce only modest symptomatic improvements in cognition with small effect sizes. A growing mismatch exists between the urgent need to develop effective drugs for symptomatic AD and the largely failed search for disease modification. The failure rate of clinical trials in AD is high overall, and in particular for disease-modifying therapies. Research efforts in AD have focused predominantly on amyloid-β and tau pathologies, but limiting clinical research to these "classical hallmarks" of the disease does not address the most urgent patient, caregiver, or societal needs. Rather, clinical research should consider the complex pathophysiology of AD. Innovative approaches are needed that provide outside-the-box thinking, and re-imagine trial design, interventions, and outcomes as well as progress in proteomics and fluid biomarker analytics for both diagnostics and disease monitoring. A new approach offering a highly specific, yet multi-pronged intervention that exerts positive modulation on the HGF/MET neurotrophic system is currently being tested in mid-to-late-stage clinical trials in mild to moderate AD. Findings from such trials may provide data to support novel approaches for development of innovative drugs for treating AD at various disease stages, including among patients already symptomatic, and may offer benefits for other neurodegenerative diseases.

Toward comprehensive value assessment for Alzheimer's disease innovations

INTRODUCTION

Assessing medical technologies for Alzheimer's disease (AD) creates challenges for current methods of value assessment. New value assessment approaches for AD are also needed.

METHODS

We adapted concepts from health economics to help guide decision makers to more informed decisions about AD therapies and diagnostics.

RESULTS

We propose a value framework based on five categories: perspective, value elements, analysis, reporting, and decision making. AD value assessments should include the perspective of the patient-caregiver dyad. We propose a broader array of value elements than currently used. Analytics and decision methods can synthesize evidence for all elements of value. Decisions should use a "deliberative appraisal" approach informed by the composite evidence and be transparently reported.

DISCUSSION

Using the proposed framework, the value of forthcoming innovations for AD may be more thoroughly assessed for and by all stakeholders. It can guide decision makers to carefully consider all relevant elements of value contributing to more holistic and transparent decision making.

RESEARCH HIGHLIGHTS

Alzheimer's disease challenges common methods of evaluating medical technology. Using current methods, new AD innovations might not be appropriately valued. Poor value assessments will adversely affect patient access to AD innovations. A full AD value framework expands perspective, elements, analysis, decision-making, reporting.

Treatment Preference for Alzheimer's Disease: A Multicriteria Decision Analysis with Caregivers, Neurologists, and Payors

INTRODUCTION

Alzheimer's disease (AD) is a chronic neurodegenerative disorder associated with a high burden of illness. New therapies under development include agents that target amyloid-beta (Aβ), a key component in AD pathogenesis. Understanding the decision-making process for new AD drugs would help determine if such therapies should be adopted by society. Multicriteria decision analysis (MCDA) was applied to three key stakeholder groups to assess treatment alternatives for AD based on a multitude of decision trade-offs covering main components of care.

METHODS

AD caregivers (n = 117), neurologists (n = 90), and payors (n = 90) from the USA received an online survey. The decision problem was broken down into four decision criterion and 12 subcriteria for two treatment scenarios: an Aβ-targeted therapy vs. the standard of care (SOC). Respondents were asked to indicate how much they preferred one option over another on a scale from 1 (equal preference) to 9 (high preference) based on each criterion and subcriterion. The decision criteria and subcriteria were weighted and presented as partial utility scores (pUS), with higher scores suggesting an increased preference for that decision-making component.

RESULTS

Caregivers and payors applied the highest value to need for intervention (mean pUS = 0.303 and 0.259) and clinical outcomes (mean pUS = 0.286 and 0.377). In contrast, neurologists placed the highest value on clinical outcomes and types of benefits (mean pUS = 0.436 and 0.248). When decision subcriteria were examined, efficacy (mean pUS = 0.115, 0.219, and 0.166) and the type of patient benefits (mean pUS = 0.135, 0.178, and 0.126) were among the most valued by caregivers, neurologists, and payors.

CONCLUSION

All groups placed the highest value on drug efficacy and types of benefit derived by patients. In contrast, cost implications were among the least important aspects in their decision-making.

Neighborhood SES and Cognitive Function Among Hispanic/Latinx Residents: Why Where You Live Matters

INTRODUCTION

Few studies have examined the impacts of neighborhood SES and individual ethnicity and SES characteristics on cognitive function in aging populations. Hispanics/Latinx are more likely to have cognitive impairment and be community dwellers than non-Hispanic Whites. Neighborhood factors can have greater impacts on the relationship between Hispanics/Latinx and cognitive function. This study examines these relationships in Nueces County, Texas.

METHODS

A mixed-effects regression analysis of data from 1,140 older adults participating in the Brain Attack Surveillance in Corpus Christi - Cognitive project from 2018 to 2020 was completed. Cognitive function was measured with the Montreal Cognitive Assessment, a cognitive screening measure. Participant addresses were geocoded to obtain census tracts, which were proxies for neighborhoods. Neighborhood SES was measured by household median income, percentage of Hispanic/Latinx residents, and percentage of residents aged ≥65 years with Medicaid, all from the American Community Survey. Interactions were used to examine the impact of neighborhood SES on ethnicity and cognitive function.

RESULTS

The sample consisted of 62.5% Hispanic/Latinx and 37.5% non-Hispanic White participants. Results from the F-statistics, test of effects, indicate that being older (F4,1138=45.04; p<0.001), being a man (F1,1130=4.35; p<0.050), having low education (F3,1121=40.83; p<0.001), completing the Montreal Cognitive Assessment test in Spanish (F1,1140=15.35; p<0.001), and being Hispanic/Latinx (F1,962=20.84; p<0.001) were all associated with lower Montreal Cognitive Assessment scores. Neighborhood income was positively associated (F1,69.6=6.95; p<0.050) with Montreal Cognitive Assessment scores. Neighborhood income (β=0.32; p<0.050) and percentage with Medicaid (β=0.06; p<0.050) independently moderated the associations between ethnicity and Montreal Cognitive Assessment scores.

CONCLUSIONS

Findings suggest that neighborhood SES could further impact cognitive function independent of individual characteristics. This could be attributed to minimal resources in communities with lower SES, impacting policies and programs for older individuals, particularly those with worse cognitive function.

Knowledge of Alzheimer's disease among the healthcare staff in a medical college hospital of India

Background

With increasing numbers of people crossing the age threshold of 65 years, there is a strong likelihood that the cases of Alzheimer's disease (AD) cases will increase manifold in the upcoming decades. It is essential for the healthcare professionals to have a reasonable background knowledge about this neurodegenerative condition. This study was done to assess the level of knowledge of AD among the healthcare staff appointed at a tertiary care hospital.

Methodology

A cross-sectional survey study was done in a tertiary care hospital with healthcare workers. The knowledge level of AD was investigated using Alzheimer's Disease Knowledge Scale (ADKS) while a self-assessment scale was used by the participants to rate their own knowledge about the disease. The extent of background knowledge was then statistically evaluated on the basis of multiple subject-oriented factors. The impact of any prior dementia-specific training was also assessed. Data were analyzed by using SPSS-23 where P value < 0.05 was considered significant.

Results

Out of a total of 124 participants recruited during the study period, the average score on the ADKS scale was 19.2 ± 3.1. Self-rated Alzheimer's scale depicted a mean value of 4.89 ± 1.7. The participants having a positive family history and personal/professional caring experience for AD did not obtain any remarkably better score. The doctors were more likely to score better than nurses and other healthcare staff (p < 0.001). Moreover, dementia-related training had a significantly better outcome in terms of promoting the knowledge base of AD (p < 0.001).

Conclusion

There is a below-par knowledge of Alzheimer's dementia among the healthcare staff of the hospital. The staff of the hospital realizes this shortcoming, and there is a need for dementia-specific training to overcome this knowledge gap.

Functionalization strategies of polymeric nanoparticles for drug delivery in Alzheimer’s disease: Current trends and future perspectives

Alzheimer’s disease (AD), the most common form of dementia, is a progressive and multifactorial neurodegenerative disorder whose primary causes are mostly unknown. Due to the increase in life expectancy of world population, including developing countries, AD, whose incidence rises dramatically with age, is at the forefront among neurodegenerative diseases. Moreover, a definitive cure is not yet within reach, imposing substantial medical and public health burdens at every latitude. Therefore, the effort to devise novel and effective therapeutic strategies is still of paramount importance. Genetic, functional, structural and biochemical studies all indicate that new and efficacious drug delivery strategies interfere at different levels with various cellular and molecular targets. Over the last few decades, therapeutic development of nanomedicine at preclinical stage has shown to progress at a fast pace, thus paving the way for its potential impact on human health in improving prevention, diagnosis, and treatment of age-related neurodegenerative disorders, including AD. Clinical translation of nano-based therapeutics, despite current limitations, may present important advantages and innovation to be exploited in the neuroscience field as well. In this state-of-the-art review article, we present the most promising applications of polymeric nanoparticle-mediated drug delivery for bypassing the blood-brain barrier of AD preclinical models and boost pharmacological safety and efficacy. In particular, novel strategic chemical functionalization of polymeric nanocarriers that could be successfully employed for treating AD are thoroughly described. Emphasis is also placed on nanotheranostics as both potential therapeutic and diagnostic tool for targeted treatments. Our review highlights the emerging role of nanomedicine in the management of AD, providing the readers with an overview of the nanostrategies currently available to develop future therapeutic applications against this chronic neurodegenerative disease.

Dementia care needs for individuals and caregivers among Mexican Americans and non-Hispanic Whites

Mexican Americans (MA) are more likely to have cognitive impairment and dementia (CID), be diagnosed at an earlier age and live with CID longer, compared to non-Hispanic Whites (NHW). While studies have examined unmet needs of individuals with CID and their caregivers, few have focused on MA populations in the U.S. This paper examines the needs of community-residing individuals with CID and their caregivers in Nueces County, Texas, a county with one of the largest MA populations in the U.S., while exploring ethnic differences in needs identified. Using concept mapping, a mixed-method approach, qualitative input on perceived needs by informal caregivers and health professionals was collected. Participants then sorted and rated perceived needs. Using this information, multidimensional scaling and cluster analyses were conducted to map the relationship between perceived needs and determine their importance and priority. Five clusters were derived for caregivers and four for the health professionals. Themes across both caregivers and health professionals highlighted the need for specialized and team-based medical care, caregiver support and training, along with socio-economic and physical needs that help with day-to-day care of individuals with CID. Among caregivers, MA rated financial resources as more important and of higher priority compared to NHW. The health professionals' perspectives were aligned with those of all caregivers. By understanding the needs of caregivers and individuals with CID, we can help families deal with this disease and let caregivers thrive. This is especially important for minority populations like MAs.

Stakeholder Insights in Alzheimer's Disease: Natural Language Processing of Social Media Conversations

BACKGROUND

Social media data may be especially effective for studying diseases associated with high stigma, such as Alzheimer's disease (AD).

OBJECTIVE

We primarily aimed to identify issues/challenges experienced by patients with AD using natural language processing (NLP) of social media posts.

METHODS

We searched 130 public social media sources between January 1998 and December 2021 for AD stakeholder social media posts using NLP to identify issues/challenges experienced by patients with AD. Issues/challenges identified by ≥10% of any AD stakeholder type were described. Illustrative posts were selected for qualitative review. Secondarily, issues/challenges were organized into a conceptual AD identification framework (ADIF) and representation of ADIF categories within clinical instruments was assessed.

RESULTS

We analyzed 1,859,077 social media posts from 30,341 AD stakeholders (21,011 caregivers; 7,440 clinicians; 1,890 patients). The most common issues/challenges were Worry/anxiety (34.2%), Pain (33%), Malaise (28.7%), Confusional state (27.1%), and Falls (23.9%). Patients reported a markedly higher volume of issues/challenges than other stakeholders. Patient posts reflected the broader scope of patient burden, caregiver posts captured both patient and caregiver burden, and clinician posts tended to be targeted. Less than 5% of the high frequency issues/challenges were in the "function and independence" and "social and relational well-being" categories of the ADIF, suggesting these issues/challenges may be difficult to capture. No single clinical instrument covered all ADIF categories; "social and relational well-being" was least represented.

CONCLUSION

NLP of AD stakeholder social media data revealed a broad spectrum of real-world insights regarding patient burden.

The genetic architecture of Alzheimer disease risk in the Ohio and Indiana Amish

Alzheimer disease (AD) is the most common type of dementia and is currently estimated to affect 6.2 million Americans. It ranks as the sixth leading cause of death in the United States, and the proportion of deaths due to AD has been increasing since 2000, while the proportion of many other leading causes of deaths have decreased or remained constant. The risk for AD is multifactorial, including genetic and environmental risk factors. Although APOE ε4 remains the largest genetic risk factor for AD, more than 26 other loci have been associated with AD risk. Here, we recruited Amish adults from Ohio and Indiana to investigate AD risk and protective genetic effects. As a founder population that typically practices endogamy, variants that are rare in the general population may be of a higher frequency in the Amish population. Since the Amish have a slightly lower incidence and later age of onset of disease, they represent an excellent and unique population for research on protective genetic variants. We compared AD risk in the Amish and to a non-Amish population through APOE genotype, a non-APOE genetic risk score of genome-wide significant variants, and a non-APOE polygenic risk score considering all of the variants. Our results highlight the lesser relative impact of APOE and differing genetic architecture of AD risk in the Amish compared to a non-Amish, general European ancestry population.

Economic Burden of Chronic Comorbidities Among Community-Dwelling Older Adults With Dementia: A Propensity Score Matched National-Level Study

OBJECTIVE

This study examined the extent to which chronic comorbidities contribute to excess health care expenditures between older adults with dementia and propensity score (PS)-matched nondementia controls.

METHODS

This was a retrospective, cross-sectional, PS-matched case (dementia): control (nondementia) study of older adults (65 y or above) using alternative years data from pooled 2005 to 2015 Medical Expenditure Panel Surveys (MEPS). Chronic comorbidities were identified based on Clinical Classifications System or ICD-9-CM codes. Ordinary least squares regression was utilized to quantify the impact of chronic comorbidities on the excess expenditures with logarithmic transformation. Expenditures were expressed as 2019 US dollars. All analyses accounted for the complex survey design of MEPS.

RESULTS

The mean yearly home health care expenditures were particularly higher among older adults with dementia and co-occurring anemia, eye disorders, hyperlipidemia, and hypertension compared with PS-matched controls. Ordinary least squares regression models revealed that home health care expenditures were 131% higher (β=0.837, P <0.001) among older adults with dementia compared with matched nondementia controls before adjusting for chronic comorbidities. When additionally adjusting for chronic comorbidities, the percentage increase, while still significant ( P <0.001) decreased from 131% to 102%.

CONCLUSIONS

The excess home health care expenditures were partially explained by chronic comorbidities among community-dwelling older adults with dementia.

Demonstration of Clinical Meaningfulness of the Integrated Alzheimer’s Disease Rating Scale (iADRS): Association Between Change in iADRS Scores and Patient and Caregiver Health Outcomes

Background:

The integrated Alzheimer’s Disease Rating Scale (iADRS) is a validated cognitive/functional composite that effectively captures cognitive and functional decline over a broad spectrum of disease. The clinical meaningfulness of change on iADRS can be supported by establishing an association with changes on important health outcome measures.

Objective:

To evaluate the relationship between change on the iADRS and changes in health outcomes in individuals with mild cognitive impairment (MCI) due to Alzheimer’s disease (AD), or mild or moderate AD dementia using placebo data from four AD clinical trials and data from one AD observational study.

Methods:

Analysis of covariate (ANCOVA) models were used to estimate the relationship between 18-month change on the iADRS and changes on health outcome measures (related to cost, quality of life, and caregiver burden). The regression coefficients for the iADRS were used to compute impact of natural disease progression and disease-modifying treatment on health outcomes. Additional ANCOVAs were conducted to understand whether cognition and/or function was the underlying explanation of any association between iADRS and health outcome change.

Results:

Across datasets and disease stages, a worsening on the iADRS was significantly associated with increased societal costs, caregiver burden (time and distress) and worsening in measures of patient quality of life.

Conclusion:

Decline on the iADRS was associated with worsening in health outcome measures. These findings suggest that the iADRS can be used in clinical trials as a proxy measure of clinically meaningful outcomes of AD progression.

Comparative salary-related costs of a brief app-directed delirium identification protocol by hospitalists, nurses, and nursing assistants

BACKGROUND

Systematic screening can improve delirium identification among hospitalized older adults. Prior studies have shown clinicians and health system leaders may believe they do not have the time and resources for assessment. We conducted a comparative salary-related cost analysis of an adaptive delirium identification protocol directed by an iPad app.

METHODS

We recruited 527 older adult medicine patients from an urban academic medical center (n = 269) and a rural community hospital (n = 258). Physicians and nurses completed the two-step Ultra-brief Confusion Assessment Method (UB-CAM) protocol (with or without a skip pattern), while certified nursing assistants completed only the UB-2 ultra-brief screen. The sample included 527 patients (average age 80, 57% women, 35% with dementia). Time required to administer the protocol was collected automatically by the iPad app. Salary-related costs of screening were determined by multiplying the time required by the hourly wage for the three disciplines, as obtained from national and regional published healthcare salary cost data. Cost estimates for entire hospital implementation were also calculated.

RESULTS

Participants were screened on 924 hospital days by 399 clinicians (53 physicians, 236 nurses, 110 CNAs). For the UB-2, CNAs cost per screen was lower than the other clinician types ($0.37 per screen vs. $0.73 for nurses and $2.39 for hospitalists). For the UB-CAM with skip (UB-CAM), costs per protocol were $1.10 for nurses vs. $3.61 for physicians. The annual salary-related costs of hospital-wide implementation of a nurse-based UB-CAM protocol in a medium-sized (300-bed) hospital was $63,015 plus $4356 for initial and annual training.

CONCLUSIONS

CNAs and nurses had the lowest salary-associated costs for app-directed CAM-based delirium screening and identification, respectively. Salary-related annual hospital costs for the most efficient protocols in a medium-sized hospital were less than the annual cost of hiring 1 FTE of the discipline performing the protocols.

The economic burden of dementia in low- and middle-income countries (LMICs): a systematic review

Introduction

More than two-thirds of people with dementia live in low- and middle-income countries (LMICs), resulting in a significant economic burden in these settings. In this systematic review, we consolidate the existing evidence on the cost of dementia in LMICs.

Methods

Six databases were searched for original research reporting on the costs associated with all-cause dementia or its subtypes in LMICs. The national-level dementia costs inflated to 2019 were expressed as percentages of each country’s gross domestic product (GDP) and summarised as the total mean percentage of GDP. The risk of bias of studies was assessed using the Larg and Moss method.

Results

We identified 14 095 articles, of which 24 studies met the eligibility criteria. Most studies had a low risk of bias. Of the 138 LMICs, data were available from 122 countries. The total annual absolute per capita cost ranged from US$590.78 for mild dementia to US$25 510.66 for severe dementia. Costs increased with the severity of dementia and the number of comorbidities. The estimated annual total national costs of dementia ranged from US$1.04 million in Vanuatu to US$195 billion in China. The average total national expenditure on dementia estimated as a proportion of GDP in LMICs was 0.45%. Indirect costs, on average, accounted for 58% of the total cost of dementia, while direct costs contributed 42%. Lack of nationally representative samples, variation in cost components, and quantification of indirect cost were the major methodological challenges identified in the existing studies.

Conclusion

The estimated costs of dementia in LMICs are lower than in high-income countries. Indirect costs contribute the most to the LMIC cost. Early detection of dementia and management of comorbidities is essential for reducing costs. The current costs are likely to be an underestimation due to limited dementia costing studies conducted in LMICs, especially in countries defined as low- income.

PROSPERO registration number

The protocol was registered in the International Prospective Register of Systematic Reviews database with registration number CRD42020191321.

2022 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report discusses consumers' and primary care physicians' perspectives on awareness, diagnosis and treatment of mild cognitive impairment (MCI), including MCI due to Alzheimer's disease. An estimated 6.5 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available. Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States in 2019 and the seventh-leading cause of death in 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. More than 11 million family members and other unpaid caregivers provided an estimated 16 billion hours of care to people with Alzheimer's or other dementias in 2021. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $271.6 billion in 2021. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the dementia care workforce have also been affected by COVID-19. As essential care workers, some have opted to change jobs to protect their own health and the health of their families. However, this occurs at a time when more members of the dementia care workforce are needed. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2022 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $321 billion. A recent survey commissioned by the Alzheimer's Association revealed several barriers to consumers' understanding of MCI. The survey showed low awareness of MCI among Americans, a reluctance among Americans to see their doctor after noticing MCI symptoms, and persistent challenges for primary care physicians in diagnosing MCI. Survey results indicate the need to improve MCI awareness and diagnosis, especially in underserved communities, and to encourage greater participation in MCI-related clinical trials.

Economic Evaluation of Healthcare Resource Utilization and Costs for Newly Diagnosed Dementia-Related Psychosis

This retrospective cohort study described changes in all-cause healthcare resource utilization (HCRU) and associated costs in dementia patients newly diagnosed with psychosis. Dementia and incident psychosis were identified using diagnostic and pharmacy claims using a Medicare 20% random sample dataset. All-cause HCRU and unweighted and weighted (by person-years of follow-up) HCRU-associated costs were evaluated in the year prior to and the 4 years following diagnosis of psychosis. In 49,509 dementia patients with psychosis, physician visits per patient per year increased from a mean of 26.7 (standard deviation (SD) 20.0) prior to psychosis to 38.4 (SD 41.9) post-psychosis diagnosis. The number of inpatient stay claims increased from 1.0 (SD 1.4) to 1.7 (SD 5.8). Mean unweighted costs for inpatient stays and home healthcare/hospice during 2008–2016 were USD 9989 and USD 3279 prior to a diagnosis of psychosis but increased to USD 25,982 and USD 9901 (weighted: USD 11,779 and USD 6709), respectively, in the year after a psychosis diagnosis. This pattern of a sharp increase in mean costs was also observed in costs adjusted to 2015 USD, and in both unweighted and weighted total and psychosis-related costs. These results indicate the importance of identifying newly diagnosed psychosis in dementia patients as well as the pressing need for management strategies and treatments that can reduce HCRU and costs.

Costs associated with treatment of insomnia in Alzheimer’s disease caregivers: a comparison of mindfulness meditation and cognitive behavioral therapy for insomnia

Background

Among the over 5 million informal caregivers for patients with Alzheimer’s disease (AD) in the United States (US), over 60% experience insomnia. Research on insomnia treatment efficacy in AD caregivers is limited. An ongoing randomized non-inferiority clinical trial, the Caregiver Sleep Research study, is evaluating whether mindfulness meditation is non-inferior to cognitive behavioral therapy for insomnia (CBT-I) in the treatment of insomnia in AD caregivers. The present report examines estimated intervention costs in this ongoing trial.

Methods

Micro-costing was used to itemize and abstract costs of the two interventions: a mindfulness-based intervention known as mindful awareness practices for insomnia (MAP-I); and CBT-I. This approach involves collecting detailed data on resources utilized and the unit costs of those resources, thereby revealing actual resource use and economic costs for each treatment arm. Personnel time, patient time, and supplies were inventoried, and unit costs were applied. Caregiver time costs, including travel, were based on US Labor Bureau home-health aide national mean hourly wages; instructor/staff costs were based on hourly wages. Per-participant and program costs were calculated assuming individual- and group-delivery to reflect real-world implementation. Sensitivity analyses evaluated robustness of estimates.

Results

From the societal perspective, per-participant MAP-I costs were $1884 for individual and $1377 for group delivery; for CBT-I, these costs were $3978 and $1981, respectively. Compared with CBT-I, MAP-I provided cost savings of $2094 (53%) and $604 (30%) per treated caregiver for individual and group delivery, respectively. From the US healthcare system perspective, MAP-I vs. CBT-I participant savings were $1872 (65%) for individual and $382 (44%) for group interventions, respectively. For MAP-I and CBT-I, instructor in-class time was the highest cost component. Results were most sensitive to combined instructor time costs.

Conclusions

Treatment of insomnia with MAP-I, compared to CBT-I, yields substantial cost savings for society and the healthcare system. With this potential for cost savings, results of the ongoing non-inferiority trial have critical implications for insomnia treatment dissemination and its benefits to AD caregivers and other community populations with insomnia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07619-w.

Pure Tone Audiometry and Hearing Loss in Alzheimer's Disease: A Meta-Analysis

An association between age-related hearing loss (ARHL) and Alzheimer's Disease (AD) has been widely reported. However, the nature of this relationship remains poorly understood. Quantification of hearing loss as it relates to AD is imperative for the creation of reliable, hearing-related biomarkers for earlier diagnosis and development of ARHL treatments that may slow the progression of AD. Previous studies that have measured the association between peripheral hearing function and AD have yielded mixed results. Most of these studies have been small and underpowered to reveal an association. Therefore, in the current report, we sought to estimate the degree to which AD patients have impaired hearing by performing a meta-analysis to increase statistical power. We reviewed 248 published studies that quantified peripheral hearing function using pure-tone audiometry for subjects with AD. Six studies, with a combined total of 171 subjects with AD compared to 222 age-matched controls, met inclusion criteria. We found a statistically significant increase in hearing threshold as measured by pure tone audiometry for subjects with AD compared to controls. For a three-frequency pure tone average calculated for air conduction thresholds at 500-1,000-2,000 Hz (0.5-2 kHz PTA), an increase of 2.3 decibel hearing level (dB HL) was found in subjects with AD compared to controls (p = 0.001). Likewise, for a four-frequency pure tone average calculated at 500-1,000-2,000-4,000 (0.5-4 kHz PTA), an increase of 4.5 dB HL was measured (p = 0.002), and this increase was significantly greater than that seen for 0.5-2 kHz PTA. There was no difference in the average age of the control and AD subjects. These data confirm the presence of poorer hearing ability in AD subjects, provided a quantitative estimate of the magnitude of hearing loss, and suggest that the magnitude of the effect is greater at higher sound frequencies. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42021288280.