Socioeconomic Disparities and Mortality After a Diagnosis of Dementia: Results From a Nationwide Registry Linkage Study

Healthcare use according to deprivation among French Alzheimer's Disease and Related Diseases subjects: a national cross-sectional descriptive study based on the FRA-DEM cohort

Introduction

Pluriprofessional and coordinated healthcare use is recommended for Alzheimer's Disease and Related Diseases (ADRD). Despite a protective health system, France is characterized by persistent and significant social inequalities in health. Although social health inequalities are well documented, less is known about social disparities in healthcare use in ADRD, especially in France. Therefore, this study aimed to describe healthcare use according to socioeconomic deprivation among ADRD subjects and the possible potentiating role of deprivation by age.

Methods

We studied subjects identified with incident ADRD in 2017 in the French health insurance database (SNDS). We described a large extent of their healthcare use during the year following their ADRD identification. Deprivation was assessed through French deprivation index (Fdep), measured at the municipality level, and categorized into quintiles. We compared healthcare use according to the Fdep quintiles through chi-square tests. We stratified the description of certain healthcare uses by age groups (40-64 years, 65-74 years, 75-84 years, 85 years, and older), number of comorbidities (0, 1, 2-3, 4 comorbidities and more), or the presence of psychiatric comorbidity.

Results

In total, 124,441 subjects were included. The most deprived subjects had less use of physiotherapy (28.56% vs. 38.24%), ambulatory specialists (27.24% vs. 34.07%), ambulatory speech therapy (6.35% vs. 16.64%), preventive consultations (62.34% vs. 69.65%), and were less institutionalized (28.09% vs. 31.33%) than the less deprived ones. Conversely, they were more exposed to antipsychotics (11.16% vs. 8.43%), benzodiazepines (24.34% vs. 19.07%), hospital emergency care (63.84% vs. 57.57%), and potentially avoidable hospitalizations (12.04% vs. 10.95%) than the less deprived ones.

Discussion and conclusion

The healthcare use of subjects with ADRD in France differed according to the deprivation index, suggesting potential health renunciation as in other diseases. These social inequalities may be driven by financial barriers and lower education levels, which contribute to health literacy (especially for preventive care). Further studies may explore them.

Identifying longitudinal healthcare pathways and subsequent mortality for people living with dementia in England: an observational group-based trajectory analysis

BACKGROUND

The number of people living with dementia (PLWD) continues to increase, particularly those with severe symptomatology. Severe symptoms and greater ill-health result in more acute care need. Early healthcare interventions can prove beneficial. Healthcare use has not been analysed as a holistic set of interlinked events. This study explores different healthcare pathways among PLWD, social or spatial inequalities in healthcare pathways and subsequent mortality risk.

METHODS

Group-based trajectory models (GBTM) were applied to electronic healthcare records. We generated clusters of PLWD with similar five-year, post-diagnosis trajectories in rates of primary and secondary healthcare use. Potential social and spatial variations in healthcare use clusters were examined. Cox Proportional Hazards used to explore variation in subsequent mortality risk between healthcare use clusters.

RESULTS

Four healthcare use clusters were identified in both early- (n = 3732) and late-onset (n = 6224) dementia populations. Healthcare use variations were noted; consistent or diminishing healthcare use was associated with lower subsequent mortality risk. Increasing healthcare use was associated with increased mortality risk. Descriptive analyses indicated social and spatial variation in healthcare use cluster membership.

CONCLUSION

Healthcare pathways can help indicate changing need and variation in need, with differential patterns in initial healthcare use post-diagnosis, producing similar subsequent mortality risk. Care in dementia needs to be more accessible and appropriate, with care catered to specific and changing needs. Better continuity of care and greater awareness of dementia in primary can enhance prospects for PLWD. Research needs to further illuminate holistic care need for PLWD, including health and social care use, inequalities in care, health and outcomes.

Socioeconomic Disparities in Neurodegenerative Disease Mortality: A Population-Based Study among Belgian Men and Women Aged 65 or Older

This study investigates the association between socioeconomic position (SEP) - in terms of income and education - and mortality from neurodegenerative diseases, that is, dementia, parkinsonism, and motor neuron diseases (MNDs). We calculated age-standardized mortality rates and mortality rate ratios using log linear Poisson regression for different SEP groups, stratified by gender, age-group, and care home residency, utilizing the 2011 Belgian census linked to register data on cause-specific mortality for 2011 to 2016. Mortality was significantly higher in the lowest educational- and income groups. The largest disparities were found in dementia mortality. Income had a strong negative effect on parkinsonism mortality, education a positive effect. We found no significant association between SEP and MND. Our study provides evidence supporting the presence of socioeconomic disparities in mortality due to neurodegeneration. We found a strong negative association between SEP and NDD mortality, which varies between NDD, gender and care home residency.

Alzheimer's disease and its related dementias in US Native Americans: A major public health concern

Alzheimer's disease (AD) and Alzheimer's related dementias (ADRD) are growing public health concerns in aged populations of all ethnic and racial groups. AD and ADRD are caused by multiple factors, such as genetic mutations, modifiable and non-modifiable risk factors, and lifestyle. Studies of postmortem brains have revealed multiple cellular changes implicated in AD and ADRD, including the accumulation of amyloid beta and phosphorylated tau, synaptic damage, inflammatory responses, hormonal imbalance, mitochondrial abnormalities, and neuronal loss. These changes occur in both early-onset familial and late-onset sporadic forms. Two-thirds of women and one-third of men are at life time risk for AD. A small proportion of total AD cases are caused by genetic mutations in amyloid precursor protein, presenilin 1, and presenilin 1 genes, and the APOE4 allele is a risk factor. Tremendous research on AD/ADRD, and other comorbidities such as diabetes, obesity, hypertension, and cancer has been done on almost all ethnic groups, however, very little biomedical research done on US Native Americans. AD/ADRD prevalence is high among all ethnic groups. In addition, US Native Americans have poorer access to healthcare and medical services and are less likely to receive a diagnosis once they begin to exhibit symptoms, which presents difficulties in treating Alzheimer's and other dementias. One in five US Native American people who are 45 years of age or older report having memory issues. Further, the impact of caregivers and other healthcare aspects on US Native Americans is not yet. In the current article, we discuss the history of Native Americans of United States (US) and health disparities, occurrence, and prevalence of AD/ADRD, and shedding light on the culturally sensitive caregiving practices in US Native Americans. This article is the first to discuss biomedical research and healthcare disparities in US Native Americans with a focus on AD and ADRD, we also discuss why US Native Americans are reluctant to participate in biomedical research.

Quantification of race/ethnicity representation in Alzheimer's disease neuroimaging research in the USA: a systematic review

BACKGROUND

Racial and ethnic minoritized groups are disproportionately at risk for Alzheimer's Disease (AD), but are not sufficiently recruited in AD neuroimaging research in the United States. This is important as sample composition impacts generalizability of findings, biomarker cutoffs, and treatment effects. No studies have quantified the breadth of race/ethnicity representation in the AD literature.

METHODS

This review identified median race/ethnicity composition of AD neuroimaging US-based research samples available as free full-text articles on PubMed. Two types of published studies were analyzed: studies that directly report race/ethnicity data (i.e., direct studies), and studies that do not report race/ethnicity but used data from a cohort study/database that does report this information (i.e., indirect studies).

RESULTS

Direct studies (n = 719) have median representation of 88.9% white or 87.4% Non-Hispanic white, 7.3% Black/African American, and 3.4% Hispanic/Latino ethnicity, with 0% Asian American, Native Hawaiian/Pacific Islander, and American Indian/Alaska Native, Multiracial, and Other Race participants. Cohort studies/databases (n = 44) from which indirect studies (n = 1745) derived are more diverse, with median representation of 84.2% white, 83.7% Non-Hispanic white, 11.6% Black/African American, 4.7% Hispanic/Latino, and 1.75% Asian American participants. Notably, 94% of indirect studies derive from just 10 cohort studies/databases. Comparisons of two time periods using a median split for publication year, 1994-2017 and 2018-2022, indicate that sample diversity has improved recently, particularly for Black/African American participants (3.39% from 1994-2017 and 8.29% from 2018-2022).

CONCLUSIONS

There is still underrepresentation of all minoritized groups relative to Census data, especially for Hispanic/Latino and Asian American individuals. The AD neuroimaging literature will benefit from increased representative recruitment of ethnic/racial minorities. More transparent reporting of race/ethnicity data is needed.

Mortality Risks and Causes of Death by Dementia Types in a Japanese Cohort with Dementia: NCGG-Stories

BACKGROUND

Prognosis-related information regarding dementia needs to be updated, as changes in medical and long-term care environments for patients with dementia in recent decades may be improving the prognosis of the disease.

OBJECTIVE

We aimed to investigate the mortality, cause of death, and prognostic factors by types of dementia in a Japanese clinic-based cohort.

METHODS

The National Center for Geriatrics and Gerontology-Life Stories of People with Dementia consists of clinical records and prognostic data of patients who visited the Memory Clinic in Japan. Patients who attended the clinic between July 2010 and September 2018, or their close relatives, were asked about death information via a postal survey. A cohort of 3,229 patients (mean age, 76.9; female, 1,953) was classified into six groups: normal cognition (NC), mild cognitive impairment (MCI), Alzheimer's disease (AD), vascular dementia, dementia with Lewy bodies (DLB), and frontotemporal lobar degeneration. A Cox proportional hazards model was employed to compare the mortality of each type of dementia, MCI, and NC.

RESULTS

Patients with all types of dementia and MCI had higher mortality rates than those with NC (hazard risks: 2.61-5.20). The most common cause of death was pneumonia, followed by cancer. In the MCI, AD, and DLB groups, older age, male sex, and low cognitive function were common prognostic factors but not presence of apolipoprotein E ɛ4 allele.

CONCLUSION

Our findings suggest important differences in the mortality risk and cause of death among patients with dementia, which will be useful in advanced care planning and policymaking.

The Impact of Educational Attainment and Income on Long-Term Care for Persons with Alzheimer's Disease and Other Dementias: A Swedish Nationwide Study

BACKGROUND

Long-term care improves independence and quality of life of persons with dementia (PWD). The influence of socioeconomic status on access to long-term care was understudied.

OBJECTIVE

To explore the socioeconomic disparity in long-term care for PWD.

METHODS

This registry-based study included 14,786 PWD, registered in the Swedish registry for cognitive and dementia disorders (2014-2016). Education and income, two traditional socioeconomic indicators, were the main exposure. Outcomes were any kind of long-term care, specific types of long-term care (home care, institutional care), and the monthly average hours of home care. The association between outcomes and socioeconomic status was examined with zero-inflated negative binomial regression and binary logistic regression.

RESULTS

PWD with compulsory education had lower likelihood of receiving any kind of long-term care (OR 0.80, 95% CI 0.68-0.93), or home care (OR 0.83, 95% CI 0.70-0.97), compared to individuals with university degrees. Their monthly average hours of home care were 0.70 times (95% CI 0.59-0.82) lower than those of persons with university degrees. There was no significant association between education and the receipt of institutional care. Stratifying on persons with Alzheimer's disease showed significant association between lower education and any kind of long-term care, and between income and the hours of home care.

CONCLUSIONS

Socioeconomic inequalities in long-term care existed in this study population. Lower-educated PWD were less likely to acquire general long-term care, home care and had lower hours of home care, compared to their higher-educated counterparts. Income was not significantly associated with the receipt of long-term care.

Effects of Socioeconomic Status and Residence Areas on Long-Term Survival in Patients With Early-Onset Dementia: The Korean National Health Insurance Service Database Study

BACKGROUND

Early-onset dementia (EOD) is still insufficiently considered for healthcare policies. We investigated the effect of socio-environmental factors on the long-term survival of patients with EOD.

METHODS

This retrospective cohort study utilized the Korean National Health Insurance Database from 2007 to 2018. We enrolled 3,825 patients aged 40 to 65 years old with all types of dementia newly diagnosed in 2009 as EOD cases. We defined socioeconomic status using the national health insurance premium (NHIP) levels. Residential areas were classified into capital, metropolitan, city, and county levels. All-cause mortality was the primary outcome. Kaplan-Meier curves and log-rank tests were employed. Further, Cox-proportional hazards models were established.

RESULTS

The mean survival of the fourth NHIP level group was 96.31 ± 1.20 months, whereas that of the medical-aid group was 85.53 ± 1.30 months (P < 0.001). The patients living in the capital had a mean survival of 95.73 ± 1.34 months, whereas those living in the county had 89.66 ± 1.75 months (P = 0.035). In the Cox-proportional hazards model, the medical-aid (adjusted hazard ratio [aHR], 1.67; P < 0.001), first NHIP level (aHR, 1.26; P = 0.012), and second NHIP level (aHR, 1.26; P = 0.008) groups were significantly associated with a higher long-term mortality risk. The capital residents exhibited a significantly lower long-term mortality risk than did the county residents (aHR, 0.82; P = 0.041).

CONCLUSION

Socioeconomic status and residential area are associated with long-term survival in patients with EOD. This study provides a rational basis for establishing a healthcare policy for patients with EOD.

Exploring community knowledge, attitudes and perceptions of Alzheimer's Disease/Alzheimer's Disease-Related Dementias and healthy ageing in Asian American, Native Hawaiian and Pacific Islanders

Alzheimer's disease and related dementias (AD/ADRD) disparities exist in the rapidly growing and extremely heterogeneous Asian American and Native Hawaiian and Pacific Islander (NH/PI) ageing populations in the United States. Limited community-clinical resources supporting culturally competent and timely diagnosis exacerbate barriers to existing care services in these populations. Community-based participatory research or community-engaged research are proven community-academic research approaches that can support the development and implementation of community-focused programmes to maximise community benefit. The NYU Center for the Study of Asian American Health engaged our national and local community partners to gain a deeper understanding of AD/ADRD in this diverse and growing population, to develop a strategic community-engaged research agenda to understand, address and reduce AD/ADRD disparities among Asian American and NH/PI communities. Findings from an initial scoping review identified significant research gaps. We conducted a series of key informant interviews (n = 11) and a modified Delphi survey (n = 14) with Asian American and NH/PI community leaders and older adult service providers followed by a facilitated group discussion of survey findings to gain consensus on key priority research areas identified in the literature and to determine culturally and contextually appropriate approaches to support AD/ADRD prevention, early identification and treatment in Asian American and NH/PI communities. Future research and health education should focus on raising Asian American and NH/PI basic individual- and community-level awareness about AD/ADRD and leveraging existing community assets to integrate effective engagement strategies to access AD/ADRD services within the healthcare system.

Prediction of physical functioning and general health status trajectories on mortality among persons with cognitive impairment

BACKGROUND

The concern posed by the confluence of aging and cognitive impairment is growing in importance as the U.S. population rapidly ages. As such, we sought to examine the predictive power of physical functioning (PF) and general health status (GHS) trajectories on mortality outcomes among persons with cognitive impairment (PCIs).

METHODS

We used group-based trajectory models to identify latent group memberships for PF trajectories in 1,641 PCIs and GHS trajectories in 2,021 PCIs from the National Health and Aging Trends Survey (2011-2018) and applied logistic regressions to predict mortality using these memberships controlling for individual characteristics.

RESULTS

We identified six trajectory groups for PF and four groups for GHS. Trajectory group memberships for both outcomes significantly predicted mortality. For PF, group memberships largely captured the average levels over time, and worse trajectories (i.e., lower baselines and faster declines) were associated with higher odds of death. The highest mortality risk was associated with the group experiencing a sharp decline early in its PF trajectory, although its average level across time was not the lowest. For GHS, we observed two groups with comparable average levels across time, but the one with a convex-shape trajectory had much higher mortality risks compared to the one with a concave-shape trajectory.

CONCLUSIONS

Our findings highlighted that health trajectories predicted mortality among PCIs, not only because of general levels but also because of the shapes of declines. Close monitoring health deterioration of PCIs is crucial to understand the health burden of this population and to make subsequent actions.

A Novel Explainability Approach for Technology-Driven Translational Research on Brain Aging

Brain aging leads to difficulties in functional independence. Mitigating these difficulties can benefit from technology that predicts, monitors, and modifies brain aging. Translational research prioritizes solutions that can be causally linked to specific pathophysiologies at the same time as demonstrating improvements in impactful real-world outcome measures. This poses a challenge for brain aging technology that needs to address the tension between mechanism-driven precision and clinical relevance. In the current opinion, by synthesizing emerging mechanistic, translational, and clinical research-related frameworks, and our own development of technology-driven brain aging research, we suggest incorporating the appreciation of four desiderata (causality, informativeness, transferability, and fairness) of explainability into early-stage research that designs and tests brain aging technology. We apply a series of work on electrocardiography-based "peripheral" neuroplasticity markers from our work as an illustration of our proposed approach. We believe this novel approach will promote the development and adoption of brain aging technology that links and addresses brain pathophysiology and functional independence in the field of translational research.

The Impact of Demographic, Socio-Economic and Geographic Factors on Mortality Risk among People Living with Dementia in England (2002-2016)

Increasing numbers of people living with dementia (PLWD), and a pressured health and social care system, will exacerbate inequalities in mortality for PLWD. There is a dearth of research examining multiple factors in mortality risk among PLWD, including application of large administrative datasets to investigate these issues. This study explored variation mortality risk variation among people diagnosed with dementia between 2002-2016, based on: age, sex, ethnicity, deprivation, geography and general practice (GP) contacts. Data were derived from electronic health records from a cohort of Clinical Practice Research Datalink GP patients in England (n = 142,340). Cox proportional hazards regression modelled mortality risk separately for people with early- and later- onset dementia. Few social inequalities were observed in early-onset dementia; men had greater risk of mortality. For early- and later-onset, higher rates of GP observations-and for later-onset only dementia medications-are associated with increased mortality risk. Social inequalities were evident in later-onset dementia. Accounting for other explanatory factors, Black and Mixed/Other ethnicity groups had lower mortality risk, more deprived areas had greater mortality risk, and higher mortality was observed in North East, South Central and South West GP regions. This study provides novel evidence of the extent of mortality risk inequalities among PLWD. Variance in mortality risk was observed by social, demographic and geographic factors, and frequency of GP contact. Findings illustrate need for greater person-centred care discussions, prioritising tackling inequalities among PLWD. Future research should explore more outcomes for PLWD, and more explanatory factors of health outcomes.

The Influence of Socioeconomic Deprivation on Dementia Mortality, Age at Death, and Quality of Diagnosis: A Nationwide Death Records Study in England and Wales 2001-2017

BACKGROUND

Socioeconomic deprivation may be an important determinant of dementia risk, mortality, and access to diagnostic services. Premature mortality from other causes and under-representation of deprived individuals in research may lead to this effect being overlooked.

OBJECTIVE

We assessed the relationship between deprivation and dementia mortality using comprehensive death certificate data for England and Wales from 2001 to 2017.

METHODS

We used standardized mortality ratios (SMR) and a Poisson model to compare likelihood of dying from dementia in each deprivation decile. We also examined the associations of deprivation with age at death from dementia, and with likelihood of receiving a diagnosis of unspecified dementia.

RESULTS

Risk of dying from dementia was higher in more deprived deciles (Mean SMR [95% CI] in decile 1 : 0.528 [0.506 to 0.550], decile 10:0.369 [0.338 to 0.400]). In 2017, 14,837 excess dementia deaths were attributable to deprivation (21.5% of all dementia deaths that year). There were dose-response associations of deprivation with likelihood of being older at death with dementia (odds ratio [95% CI] for decile 10 (least deprived): 1.31 [1.28 to 1.33] relative to decile 1), and with likelihood of receiving a diagnosis of unspecified dementia (odds ratio [95% CI] for decile 10:0.78 [0.76 to 0.80] relative to decile 1).

CONCLUSION

Socioeconomic deprivation in England and Wales is associated with increased dementia mortality, younger age at death with dementia, and poorer access to specialist diagnosis. Reducing social inequality may have a role in the prevention of dementia mortality.

Economic Status and Mortality in Patients with Alzheimer's Disease in Japan: The Longevity Improvement and Fair Evidence Study

OBJECTIVES

As more countries are implementing measures to address Alzheimer's disease (AD), it is essential to update the available knowledge on the relationship between economic status and mortality in patients with AD. This study examined the influence of economic status on mortality in Japanese individuals with AD using a medical claims dataset.

DESIGN

This was a retrospective cohort study.

SETTING AND PARTICIPANTS

Medical claims data from April 2014 to March 2019 were obtained from 13 local cities participating in the Longevity Improvement and Fair Evidence study. The inclusion criteria were patients aged 65 years and older who were newly diagnosed with AD during the study period.

METHODS

The outcome was death during the follow-up period. We assessed economic status by household income (middle to high income and low income); data were obtained from the use of the Medical Expenditure Ceiling Application and Standard Copayment Reduction Card (fee reduction card) when receiving an AD diagnosis, as an indicator of low-income status. We performed multivariate Cox proportional hazards analyses to examine the relationship between economic status and mortality; the model was adjusted for age, sex, the Charlson comorbidity index, and antidementia drug use.

RESULTS

We identified 39,081 newly diagnosed patients with AD from the Longevity Improvement and Fair Evidence study database (mean age, 83.6 years; female, 67.1%). Of these, 3189 individuals were identified as having a low-income status. After adjusting for possible confounders, low-income status was associated with mortality (hazard ratio, 1.95; 95% confidence interval, 1.84-2.07).

CONCLUSIONS AND IMPLICATIONS

Low-income status was associated with substantially poorer prognoses in new AD cases, indicating a need for a thorough examination of medical and nursing care services utilized by low-income individuals with AD and to explore improvement strategies.

Racial Differences in Alzheimer's Disease Specialist Encounters Are Associated with Usage of Molecular Imaging and Dementia Medications: An Enterprise-Wide Analysis Using i2b2

Background:

African Americans are at increased risk for Alzheimer’s disease (AD) but barriers to optimal clinical care are unclear.

Objective:

To comprehensively evaluate potential racial differences in the diagnosis and treatment of AD in an academic medical center.

Methods:

We used the clinical informatics tool, i2b2, to analyze all patient encounters for AD or mild cognitive impairment (MCI) in the University of Alabama at Birmingham Health System over a three-year period, examining neuroimaging rates and dementia-related medication use by race and clinic site using ratio tests on contingency tables of stratified patient counts.

Results:

Enterprise-wide, African Americans were not underrepresented among outpatients seen for AD/MCI. However, there were differences in the clinic setting where visits occurred, with African Americans overrepresented in Geriatrics and primary care clinics and underrepresented in Memory Disorders specialty clinics. There were no racial differences in the rates at which any clinic ordered PET neuroimaging tests or dementia-related medications. However, unsurprisingly, specialty clinics ordered both PET neuroimaging and dementia-related medications at a higher rate than primary care clinics, and overall across the medical enterprise, African Americans were statistically less likely to have PET neuroimaging or dementia-related medications ordered.

Conclusion:

African Americans with AD/MCI were not underrepresented at this academic medical center but were somewhat less likely to have PET neuroimaging or to be on dementia-related medications, potentially in part from underrepresentation in the specialty clinics where these orders are more likely. The reasons for this underrepresentation in specialty clinics are likely multifactorial and important to better understand.

Anticholinergic drug use and risk of mortality for people with dementia in Northern Ireland

OBJECTIVE

Anticholinergic burden refers to the cumulative effect of medications which contain anticholinergic properties. We assessed how anticholinergic burden and different types of anticholinergic medications influence mortality rates among people with dementia in Northern Ireland. Our secondary aim was to determine what demographic characteristics predict the anticholinergic burden of people with dementia.

METHODS

Data were extracted from the Enhanced Prescribing database for 25,418 people who were prescribed at least one dementia management medication between 2010 and 2016. Information was also extracted on the number of times each available anticholinergic drug was prescribed between 2010 and 2016, allowing the calculation of an overall anticholinergic burden. Cox proportional hazard models were used to determine how anticholinergic burden influenced mortality whilst multilevel model regression determined what demographic characteristics influence overall anticholinergic burden.

RESULTS

Of the 25,418 people with dementia, only 15% (n = 3880) had no anticholinergic burden. Diazepam (42%) and risperidone (18%) were the two most commonly prescribed drugs. Unadjusted Cox proportional hazard models indicated that higher anticholinergic burden was associated with significantly higher mortality rates in comparison to people with dementia who had no anticholinergic burden (HR = 1.59: 95% CI = 1.07-2.36). In particular, urological (HR = 1.20: 95% CI = 1.05-1.38) and respiratory (HR = 1.17: 95% CI = 1.08-1.27) drugs significantly increased mortality rates. People with dementia living in areas with low levels of deprivation had significantly lower anticholinergic burden (HR=-.39: 95% CI=-.47:-30).

CONCLUSIONS

Reducing anticholinergic burden is essential for people with dementia. Further research should address the unfavourable prognosis of people living with dementia in highly deprived areas.

Influence of Education and Income on Receipt of Dementia Care in Sweden

OBJECTIVE

To explore the dementia diagnostic process and drug prescription for persons with dementia (PWD) with different socioeconomic status (SES).

DESIGN

Register-based cohort study.

SETTING AND PARTICIPANTS

This study included 74,414 PWD aged ≥65 years from the Swedish Dementia Register (2007-2018). Their data were linked with the Swedish Longitudinal Integrated Database for Health Insurance and Labor Market Studies (2006-2017) to acquire the SES information 1 year before dementia diagnosis.

METHODS

Education and income-2 traditional SES indicators-were divided into 5 levels. Outcomes comprised the dementia diagnostic examinations, types of dementia diagnosis, diagnostic unit, and prescription of antidementia drugs. Binary logistic regression was performed to evaluate socioeconomic inequalities.

RESULTS

Compared to PWD with the lowest educational level, PWD with the highest educational level had a higher probability of receiving the basic diagnostic workup [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.10-1.29], clock test (OR 1.12, 95% CI 1.02-1.24) and neuroimaging (OR 1.23, 95% CI 1.09-1.39). Compared with PWD in the lowest income quintile, PWD in the highest income quintile presented a higher chance of receiving the basic diagnostic workup (OR 1.35, 95% CI 1.26-1.46), clock test (OR 1.40, 95% CI 1.28-1.52), blood analysis (OR 1.21, 95% CI 1.06-1.39), Mini-Mental State Examination (OR 1.47, 95% CI 1.26-1.70), and neuroimaging (OR 1.30, 95% CI 1.18-1.44). PWD with higher education or income had a higher likelihood of obtaining a specified dementia diagnosis or being diagnosed at a memory clinic. SES presented no association with prescription of antidementia medication, except for the association between education and the use of memantine.

CONCLUSIONS AND IMPLICATIONS

Higher education or income was significantly associated with higher chance of receiving dementia diagnostic examinations, a specified dementia diagnosis, being diagnosed at a memory clinic, and using memantine. Socioeconomic inequalities in dementia diagnostic process and prescription of memantine occurred among PWD with different education or income levels.

Social deprivation predicts adverse health outcomes after hospital admission with hip fracture in England

We found social deprivation to be associated with higher mortality in the year following hip fracture among men and women aged 60 years and older in England. In those who did survive, deprivation was associated with longer hospital stays and greater risk of subsequent emergency readmission particularly for patients with dementia.

INTRODUCTION

Social deprivation predicts a range of adverse health outcomes; however, its impact on outcomes following hip fracture is not established. We examined the effect of area-level social deprivation on outcomes following hospital admission for hip fracture in England.

METHODS

We used English Hospital Episodes Statistics linked to the National Hip Fracture Database (April 2011-March 2015) and Office for National Statistics mortality database, to identify patients aged 60+ years admitted with hip fracture. Deprivation was measured using Index of Multiple Deprivation quintiles; Q1-least deprived; Q5-most deprived, and outcomes by mortality over 1-year, length-of-stay in NHS acute and rehabilitation hospitals ('superspell'), and emergency 30-day readmission.

RESULTS

We identified 218,907 admissions with an index hip fracture (mean age 82.8 [standard deviation, SD 8.4] years; 72.6% female). Each quintile of deprivation was associated with greater mortality; age-adjusted 30-day mortality odds ratio, OR 1.30 [95% confidence interval, CI: 1.24, 1.37], p < 0.001, equating to on average 1038 fewer deaths/year among those who are least deprived (Q1 versus 2-5). Similarly, at 365 days, those most deprived had 24% higher mortality (age-sex-comorbidity-adjusted OR:1.24 [1.20, 1.28], p < 0.001; Q5 versus Q1). Among survivors, mean superspell was longer in the most versus least deprived (Q5:24.4 [SD 21.7] days, Q1:23.3 [SD 22.1], p < 0.001). Readmission was more common in those most versus least deprived (age-sex-comorbidity-adjusted OR 1.27 [1.22, 1.32], p < 0.001).

CONCLUSION

Greater deprivation is associated with reduced survival at all timepoints in the year following hip fracture. Among survivors, hospital stay is increased as is readmission risk. The extent to which configuration of English hospital services, rather than patient case-mix, explains these apparent health inequalities remains to be determined.

Factors Associated with Mortality Including Nursing Home Transitions: A Retrospective Analysis of 25,418 People Prescribed Anti-Dementia Drugs in Northern Ireland

BACKGROUND

Understanding factors associated with mortality after a dementia diagnosis can provide essential information to the person with dementia, their family, and caregivers. To date very little is known about the factors associated with mortality after a dementia diagnosis in Northern Ireland.

OBJECTIVE

To determine how demographic and other factors such as deprivation and comorbidity medications influence mortality rates after a dementia diagnosis in Northern Ireland and whether these factors are influenced through nursing home transitions.

METHODS

25,418 people prescribed anti-dementia medication were identified through the enhanced prescribing database between 2010 and 2016. The impact of covariates including age, gender, marital status, deprivation measure, urban/rural classification, and comorbidity medications were examined using cox proportional hazard models with hazard ratios (HR) and 95% confidence intervals.

RESULTS

Between 2010 and 2016, 12,129 deaths occurred, with 114 deaths/1,000 person years. Males had significantly higher mortality rates in comparison to females (HR = 1.28; 95% CI = 1.23-1.33); this was true regardless of whether the person with dementia transitioned to a nursing home. People prescribed anti-dementia drugs living with lower levels of deprivation had significantly lower mortality rates in comparison to people living with the highest levels of deprivation (HR = 0.93; 95% CI = 0.89-0.97). Diabetic (HR = 1.18; 95% CI = 1.07-1.29) and anti-arrhythmic (HR = 2.44; 95% CI = 1.01-5.91) medication in particular significantly influenced mortality.

CONCLUSION

Male gender, higher comorbidity medications, and living in areas of higher deprivation significantly increased mortality rates for people prescribed anti-dementia drugs in our study population. When comorbidity medications were classified, only anti-arrhythmia and diabetic medications significantly increased mortality. Future research should continue to investigate factors which influence mortality after a dementia diagnosis.

Impact of individual and neighborhood dimensions of socioeconomic status on the prevalence of mild cognitive impairment over seven-year follow-up

Objectives: There is strong evidence about the association between low socioeconomic status (SES) and higher risk of dementia. However, it has not been conveniently addressed so far the role of SES on the incidence of mild cognitive impairment (MCI). This study examines the impact of individual and neighbourhood dimensions of SES, as well as their interaction, on the risk of developing MCI in a sample of older adults.Method: Data from the Vallecas Project cohort, an ongoing community-based longitudinal study for early detection of cognitive impairment and dementia, were used to build two indices of SES namely individual and neighbourhood, as well as a global SES as a combination of both, and to investigate their effects on MCI conversion by means of a multivariate-adjusted Cox proportional hazard model.Results: A total of 1180 participants aged 70 years and older were enrolled in this study. Of these, 199 cases of MCI (16.9%) were diagnosed at any point of the follow-up. The individual and neighbourhood dimensions of SES played different roles in the dynamics of the MCI occurrence through aging. Most importantly, the risk of developing MCI was almost double for lower SES quartiles when compared to the highest one.Conclusion: The incidence of MCI in older adults was related to both individual characteristics and socioeconomic context. Public health strategies should be holistic and focus not only on promoting the classical individual preventive measures, but also on reducing social inequalities to foster healthy aging and reduce dementia burden.

Socio-economic predictors of time to care home admission in people living with dementia in Wales: A routine data linkage study

OBJECTIVES

Limited research has shown that people with dementia (PwD) from lower socio-economic backgrounds can face difficulties in accessing the right care at the right time. This study examined whether socio-economic status (SES) and rural versus urban living location are associated with the time between diagnosis and care home admission in PwD living in Wales, UK.

METHODS/DESIGN

This study linked routine health data and an e-cohort of PwD who have been admitted into a care home between 2000 and 2018 living in Wales. Survival analysis explored the effects of SES, living location, living situation, and frailty on the time between diagnosis and care home admission.

RESULTS

In 34,514 PwD, the average time between diagnosis and care home admission was 1.5 (±1.4) years. Cox regression analysis showed that increased age, living alone, frailty, and living in less disadvantaged neighbourhoods were associated with faster rate to care home admission. Living in rural regions predicted a slower rate until care home admission.

CONCLUSIONS

This is one of the first studies to show a link between socio-economic factors on time to care home admission in dementia. Future research needs to address variations in care needs between PwD from different socio-economic and geographical backgrounds.

The associations between social, built and geophysical environment and age-specific dementia mortality among older adults in a high-density Asian city

Background

Although socio-environmental factors which may affect dementia have widely been studied, the mortality of dementia and socio-environmental relationships among older adults have seldom been discussed.

Method

A retrospective, observational study based on territory-wide register-based data was conducted to evaluate the relationships of four individual-level social measures, two community-level social measures, six short-term (temporally varying) environmental measures, and four long-term (spatially varying) environmental measures with dementia mortality among older adults in a high-density Asian city (Hong Kong), for the following decedents: (1) all deaths: age >= 65, (2) “old-old”: age > = 85, (3) “mid-old”: aged 75–84, and (4) “young-old”: aged 65–74.

Results

This study identified 5438 deaths (3771 old-old; 1439 mid-old; 228 young-old) from dementia out of 228,600 all-cause deaths among older adults in Hong Kong between 2007 and 2014. Generally, regional air pollution, being unmarried or female, older age, and daily O₃ were associated with higher dementia mortality, while more urban compactness and greenness were linked to lower dementia mortality among older adults. Specifically, being unmarried and the age effect were associated with higher dementia mortality among the “old-old”, “mid-old” and “young-old”. Regional air pollution was linked to increased dementia mortality, while urban compactness and greenness were associated with lower dementia mortality among the “old-old” and “mid-old”. Higher daily O₃ had higher dementia mortality, while districts with a greater percentage of residents whose native language is not Cantonese were linked to lower dementia mortality among the “old-old”. Economic inactivity was associated with increased dementia mortality among the “young-old”. Gender effect varied by age.

Conclusion

The difference in strengths of association of various factors with dementia mortality among different age groups implies the need for a comprehensive framework for community health planning. In particular, strategies for air quality control, usage of greenspace and social space, and activity engagement to reduce vulnerability at all ages are warranted.

Modeling Large Sparse Data for Feature Selection: Hospital Admission Predictions of the Dementia Patients Using Primary Care Electronic Health Records

A growing elderly population suffering from incurable, chronic conditions such as dementia present a continual strain on medical services due to mental impairment paired with high comorbidity resulting in increased hospitalization risk. The identification of at risk individuals allows for preventative measures to alleviate said strain. Electronic health records provide opportunity for big data analysis to address such applications. Such data however, provides a challenging problem space for traditional statistics and machine learning due to high dimensionality and sparse data elements. This article proposes a novel machine learning methodology: entropy regularization with ensemble deep neural networks (ECNN), which simultaneously provides high predictive performance of hospitalization of patients with dementia whilst enabling an interpretable heuristic analysis of the model architecture, able to identify individual features of importance within a large feature domain space. Experimental results on health records containing 54,647 features were able to identify 10 event indicators within a patient timeline: a collection of diagnostic events, medication prescriptions and procedural events, the highest ranked being essential hypertension. The resulting subset was still able to provide a highly competitive hospitalization prediction (Accuracy: 0.759) as compared to the full feature domain (Accuracy: 0.755) or traditional feature selection techniques (Accuracy: 0.737), a significant reduction in feature size. The discovery and heuristic evidence of correlation provide evidence for further clinical study of said medical events as potential novel indicators. There also remains great potential for adaption of ECNN within other medical big data domains as a data mining tool for novel risk factor identification.

Effects of socioeconomic status on mortality after Parkinson's disease: A nationwide population-based matched cohort study in Korean populations

INTRODUCTION

To evaluate the mortality rate and impact of SES on mortality in PD using a nationwide cohort in Korea.

METHODS

We selected patients diagnosed with PD (ICD-10 code: G20) and registration code for PD (V124) in the program for rare intractable diseases between 2004 and 2015. After that, atypical parkinsonism was excluded. A matched cohort of individuals without PD were enrolled by randomly matching patients by sex, age, and year of diagnosis to the PD group with a ratio of 1:9. Cox proportional hazard models were used to identify the effects of SES on mortality using Hazard Ratios and 95% confidence intervals.

RESULTS

In total, 26,570 participants were enrolled. The mortality rate was 30.37% in PD cohort and 16.69% in the comparison cohort. According to income level, PD patients in low-middle group revealed significantly decreased HRs of 0.704 (95% CI, 0.533-0.930) compared to those in the lowest group. The medical aid group showed an increased mortality rate (HR = 1.552, 95% CI, 1.191-2.021) compared to the national health insurance group. In the subgroup analyses, medical aid was associated with mortality only in PD with female (HR = 1.740, 95% CI, 1.242-2.438) or aged 60-79 years (HR = 1.434, 95% CI 1.005-2.045). There was no significant difference in mortality rate according to residential area in PD.

CONCLUSIONS

In Korea, individual level low SES including income level and insurance type were significantly associated with increased mortality, whereas regional level SES (residential area) was not related with mortality on PD.

Risk factors of mortality in older patients with dementia in psychiatric care

OBJECTIVE

To examine the mortality risk, and its risk factors, of older patients with dementia in psychiatric care.

METHODS

We constructed a cohort of dementia patients through data linkage of four Dutch registers: the Psychiatric Case Register Middle Netherlands (PCR-MN), the hospital discharge register, the population register, and the national cause of death register. All dementia patients in PCR-MN aged between 60 and 100 years between 1 January 2000 and 31 December 2010 were included. Risk factors of mortality were investigated using Cox proportional hazard regression models with adjustment for age, sex, setting of care, nationality, marital status, dementia type, and psychiatric and somatic comorbidities.

RESULTS

In total, 4297 patients were included with a median age of 80 years. The 1-year, 3-year, and 5-year mortality were 16.4%, 44.4%, and 63.5%, respectively. Determinants that increased the 1-year mortality were: male sex (adjusted hazard ratio [HR]: 1.49; 95% confidence interval [95% CI], 1.26-1.76), higher age (HR 1.08; 95% CI, 1.07-1.09), inpatient psychiatric care (HR 1.52; 95% CI, 1.19-1.93), more somatic comorbidities (HR 1.67; 95% CI, 1.49-1.87), and cardiovascular disease separately (HR 1.54; 95% CI, 1.30-1.82). Results for 3-year and 5-year mortality were comparable. Living together/married increased the 3- and 5-year mortality, and Dutch nationality increased the 5-year mortality. There were no differences in mortality with different types of psychiatric comorbidity.

CONCLUSION

Mortality of dementia patients in psychiatric care was high, much higher than mortality in the general older population. The results of this study should raise awareness about their unfavourable prognosis, particularly older patients, men, inpatients, and patients with more somatic comorbidity.

Socio-economic status and dementia onset among older Japanese: A 6-year prospective cohort study from the Japan Gerontological Evaluation Study

OBJECTIVES

Lower socio-economic status (SES) may be associated with dementia later in life, but there is inconsistent evidence supporting this claim. We aim to examine the association between three SESs (education, job, and income indicators) and dementia onset in older adults.

METHODS

Study design was a 6-year prospective cohort study. Participants included a total of 52 063 community-dwelling adults aged 65 years or older without long-term care needs from the Japan Gerontological Evaluation Study. Outcome variable was dementia onset. Explanatory variables were educational years, the longest job held, and equivalised household income. We performed Cox proportional hazard analysis by gender with multiple imputation.

RESULTS

During the follow-up period, 10.5% of participants acquired dementia. The adjusted risks of dementia incidence of the participants with less than 6 years of education were 1.34 times (95% confidence interval [CI], 1.04-1.73) in men and 1.21 (1.00-1.45) times in women higher than those with more than 13 years of education. Females with less than 1.99 million yen (hazard ratio = 0.83, 0.72-0.96) of equivalised income were less likely to acquire dementia than those with four million yen or higher.

CONCLUSIONS

Educational attainment had a robust impact on dementia onset compared with the other SES factors in both genders of older Japanese people. Securing an education for children could be crucial to prevent dementia later in life. The longest job held was less likely to be risks of dementia incidence, compared with the other two factors.

Mortality After First Hospital Admission for Inflammatory Bowel Disease: A Nationwide Registry Linkage Study

BACKGROUND

The goal of this study was to determine long-term mortality and causes of death in patients after hospitalization for inflammatory bowel disease (IBD).

METHODS

A cohort of patients admitted to the hospital because of IBD for the first time between 1998 and 2010 was identified by linkage of nationwide Dutch registries. Mortality risks and causes of death in Crohn's disease (CD) and ulcerative colitis (UC) patients were compared with a large random sample of individuals from the general population. Multivariable Cox regression models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

In total, 23,003 patients (56.1% women; mean age, 44.8 years) were hospitalized for IBD. Patients admitted for IBD had a higher risk of death than those from the general population. Adjusted HRs for 5-year all-cause mortality were 2.42 (95% CI, 1.15-5.12) and 1.45 (95% CI, 1.26-1.66) in men and women hospitalized for CD, respectively. Corresponding HRs for UC were 1.59 (95% CI, 1.39-1.83) and 1.13 (95% CI, 0.98-1.31). Mortality among patients after hospitalization for IBD decreased between 1998-2004 and 2005-2010. Patients admitted for UC had a higher risk of all-cause mortality than those admitted for CD. Inflammatory bowel disease patients died more often from (colorectal) cancer and gastrointestinal disease and less often from cardiovascular disease relative to the general population.

CONCLUSIONS

Mortality of patients after hospitalization for IBD has decreased over time. Causes of death in CD and UC patients differ from those in the general population.

Huntington's disease in the United States: Variation by demographic and socioeconomic factors

BACKGROUND

Despite extensive research regarding the etiology of Huntington's disease, relatively little is known about the epidemiology of this rare disorder, particularly in the United States where there are no national-scale estimates of the disease.

OBJECTIVES

To provide national-scale estimates of Huntington's disease in a U.S. population and to test whether disease rates are increasing, and whether frequency varies by race, ethnicity, or other factors.

METHODS

Using an insurance database of over 67 million enrollees, we retrospectively identified a cohort of 3,707 individuals diagnosed with Huntington's disease between 2003 and 2016. We estimated annual incidence, annual diagnostic frequency, and tested for trends over time and differences in diagnostic frequency by sociodemographic characteristics.

RESULTS

During the observation period, the age-adjusted cumulative incidence rate was1.22 per 100,000 persons (95% confidence interval: 1.53, 1.65), and age-adjusted diagnostic frequency was 6.52 per 100,000 persons (95% confidence interval: 5.31, 5.66); both rates remained relatively stable over the 14-year period. We identified several previously unreported differences in Huntington's disease frequency by self-reported sex, income, and race/ethnicity. However, racial/ethnic differences were of lower magnitude than have previously been reported in other country-level studies.

CONCLUSIONS

In these large-scale estimates of U.S. Huntington's disease epidemiology, we found stable disease frequency rates that varied by several sociodemographic factors. These findings suggest that disease patterns may be more driven by social or environmental factors than has previously been appreciated. Results further demonstrate the potential utility of administrative Big Data in rare disease epidemiology when other data sources are unavailable. © 2019 International Parkinson and Movement Disorder Society.

Time-varying effects of socio-demographic and economic factors on the use of institutional long-term care before dementia-related death: A Finnish register-based study

OBJECTIVES

The effects of socio-demographic and economic factors on institutional long-term care (LTC) among people with dementia remain unclear. Inconsistent findings may relate to time-varying effects of these factors as dementia progresses. To clarify the question, we estimated institutional LTC trajectories by age, marital status and household income in the eight years preceding dementia-related and non-dementia-related deaths.

METHODS

We assessed a population-representative sample of Finnish men and women for institutional LTC over an eight-year period before death. Deaths related to dementia and all other causes at the age of 70+ in 2001-2007 were identified from the Death Register. Dates in institutional LTC were obtained from national care registers. We calculated the average and time-varying marginal effects of age, marital status and household income on the estimated probability of institutional LTC use, employing repeated-measures logistic regression models with generalised estimating equations (GEE).

RESULTS

The effects of age, marital status and household income on institutional LTC varied across the time before death, and the patterns differed between dementia-related and non-dementia-related deaths. Among people who died of dementia, being of older age, non-married and having a lower income predicted a higher probability of institutional LTC only until three to four years before death, after which the differences diminished or disappeared. Among women in particular, the probability of institutional LTC was nearly equal across age, marital status and income groups in the last year before dementia-related death. Among those who died from non-dementia-related causes, in contrast, the differences widened until death.

CONCLUSIONS

We show that individuals with dementia require intensive professional care at the end of life, regardless of their socio-demographic or economic resources. The results imply that the potential for extending community living for people with dementia is likely to be difficult through modification of their socio-demographic and economic environments.

Pre-ESRD Dementia and Post-ESRD Mortality in a Large Cohort of Incident Dialysis Patients

BACKGROUND

Conservative management may be a desirable option for elderly, fragile, or demented patients who reach end-stage renal disease (ESRD), yet some patients with dementia are placed on renal replacement therapy nonetheless.

METHODS

From a nationwide cohort of 45,076 US veterans who transitioned to ESRD over 4 contemporary years (October 1, 2007 to September 30, 2011), we identified 1,336 (3.0%) patients with International Classification of Diseases, Ninth Revision, Clinical Modification code-based dementia diagnosis during the prelude (predialysis) period. We examined the association of prelude dementia with all-cause mortality within the first 6 months following transition to dialysis, using a propensity-matched cohort and Cox proportional hazards models.

RESULTS

In the entire cohort, the overall mean ± standard deviation age at baseline was 72 ± 11 years, 95% were male, 23% were African-American, and 66% were diabetic. There were 8,080 (18.5%) deaths (mortality rate, 412; 95% confidence interval [CI], 403-421/1,000 patient-years) in the dementia-negative group, and 396 (29.6%) deaths (mortality rate, 708; 95% CI, 642-782/1,000 patient-years) in the dementia-positive group in the entire cohort in the first 6 months after dialysis initiation. Presence of dementia was associated with higher risk of all-cause mortality (adjusted hazard ratio, 1.25; 95% CI, 1.12-1.38) compared to dementia-free patients in the first 6 months after dialysis initiation.

CONCLUSION

Pre-ESRD dementia is associated with increased risk of early post-ESRD mortality in veterans transitioning to dialysis.