Cost of illness of Alzheimer's disease: how useful are current estimates?

Cost of bladder cancer in Lebanon before and after the economic collapse: a probabilistic modeling study

BACKGROUND AND OBJECTIVES

Lebanon has one of the highest incidence rates of bladder cancer (BC) in the world. In 2019, Lebanon's economy collapsed which majorly impacted healthcare costs and coverage. This study assesses the overall direct costs of urothelial BC in Lebanon, from the perspective of public and private third-party payers (TPP) and households, and evaluates the impact of the economic collapse on these costs.

METHODS

This was a quantitative, incidence-based cost-of-illness study, conducted using a macro-costing approach. Costs of medical procedures were obtained from the records of various TPPs and the Ministry of Public Health. We modeled the clinical management processes for each stage of BC, and conducted probabilistic sensitivity analyses to estimate and compare the cost of each stage, pre-and post-collapse, and for each payer category.

RESULTS

Before the collapse, the total annual cost of BC in Lebanon was estimated at LBP 19,676,494,000 (USD 13,117,662). Post-collapse, the total annual cost of BC in Lebanon increased by 768% and was estimated at LBP 170,727,187,000 (USD 7,422,921). TPP payments increased by 61% whereas out-of-pocket (OOP) payments increased by 2,745% resulting in a decrease in TPP coverage to only 17% of total costs.

CONCLUSION

Our study shows that BC in Lebanon constitutes a significant economic burden costing 0.32% of total health expenditures. The economic collapse induced an increase of 768% in the total annual cost, and a catastrophic increase in OOP payments.

Costs of Dementia in Low- And Middle-Income Countries: A Systematic Review

BACKGROUND

The proportion of people living with dementia in low- and middle-income countries (LMICs) is expected to reach 71% by 2050. Appraising the economic burden of the disease may contribute to strategic policy planning.

OBJECTIVE

To review studies conducted on the costs of dementia in LMICs, describe their methodology and summarize available costs estimates.

METHODS

Systematic review, including a search of health, economics, and social science bibliographic databases. No date or language restrictions were applied. All studies with a direct measure of the costs of dementia care were included.

RESULTS

Of the 6,843 publications reviewed, 17 studies from 11 LMICs were included. Costs of dementia tended to increase with the severity of the disease. Medical costs were greater in the mild stage, while social and informal care costs were highest in the moderate and severe stages. Annual cost estimates per patient ranged from PPP$131.0 to PPP$31,188.8 for medical costs; from PPP$16.1 to PPP$10,581.7 for social care services and from PPP$140.0 to PPP$25,798 for informal care. Overall, dementia care can cost from PPP$479.0 to PPP$66,143.6 per year for a single patient.

CONCLUSION

Few studies have been conducted on the costs of dementia in LMICs, and none so far in Africa. There seems to be a need to provide accurate data on the burden of disease in these countries to guide public health policies in the coming decades.

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.

The Effects of Home Care Provider Mix on the Care Recipient: An International, Systematic Review of Articles from 2000 to 2020

In this systematic review, we examine the literature from 2000 to 2020 to ascertain whether we can make strong conclusions about the relative benefit of adding informal care or formal care providers to the care mix among individuals receiving care in the home, specifically focusing on care recipient outcomes. We evaluate how informal care and formal care affect (or are associated with) health care use of care recipients, health care costs of care recipients, and health outcomes of care recipients. The literature to date suggests that informal care, either alone or in concert with formal care, delivers improvements in the health and well-being of older adults receiving care. The conclusions one can draw about the effects of formal care are less clear.

Multi-Target Drug Candidates for Multifactorial Alzheimer's Disease: AChE and NMDAR as Molecular Targets

Alzheimer's disease (AD) is one of the most common forms of dementia among elder people, which is a progressive neurodegenerative disease that results from a chronic loss of cognitive activities. It has been observed that AD is multifactorial, hence diverse pharmacological targets that could be followed for the treatment of AD. The Food and Drug Administration has approved two types of medications for AD treatment such as cholinesterase inhibitors (ChEIs) and N-methyl-D-aspartic acid receptor (NMDAR) antagonists. Rivastigmine, donepezil, and galantamine are the ChEIs that have been approved to treat AD. On the other hand, memantine is the only non-competitive NMDAR antagonist approved in AD treatment. As compared with placebo, it has been revealed through clinical studies that many single-target therapies are unsuccessful to treat multifactorial Alzheimer's symptoms or disease progression. Therefore, due to the complex nature of AD pathophysiology, diverse pharmacological targets can be hunted. In this article, based on the entwined link of acetylcholinesterase (AChE) and NMDAR, we represent several multifunctional compounds in the rational design of new potential AD medications. This review focus on the significance of privileged scaffolds in the generation of the multi-target lead compound for treating AD, investigating the idea and challenges of multi-target drug design. Furthermore, the most auspicious elementary units for designing as well as synthesizing hybrid drugs are demonstrated as pharmacological probes in the rational design of new potential AD therapeutics.

Real World Cost-of-Illness Evidence in Hepatitis C Virus: A systematic review

BACKGROUND

The introduction of direct-acting antivirals (DAAs) represents a potential clinical cure for hepatitis C virus (HCV) infection. Identification of costs associated with different stages of untreated disease through cost-of-illness (COI) evaluation helps inform policy decisions and cost-effectiveness analyses (CEAs). This study's objective was to review published real-world costs for patients with HCV to estimate the COI across different stages of disease progression.

METHODS

A literature search of EMBASE, Scopus, and PubMed from January 1, 2010 to August 31, 2019 was conducted to identify real-world evidence related to HCV. Data extraction included citation details, population, study type, costing method used, currency and inflation adjustments, and disease-specific costs. Standardized costing method categories (sum all medical, sum diagnosis specific, matching, regression, other incremental, and other total) were assigned. The risk of bias was assessed at the outcome level for influence on costs attributable to HCV.

RESULTS

The search strategy identified 278 studies, with 31 included in the final review after inclusion and exclusion criteria were applied. Retrospective cohorts (77%) and cross-sectional analyses (16%) were most frequently encountered. Sum Diagnosis Specific was the most common costing method (39%), followed by Regression (32%). Of the 31 studies analyzed, 35% included costs that would be included in a societal model. Costs were identified for various stages and complications related to HCV disease progression. Several studies included were determined to have a high (48%) or moderate risk (42%) of bias related to COI estimates.

CONCLUSION

Cost estimates for formal, informal, and non-health care services were identified in this review, but several challenges still exist in fully quantifying HCV burden. Future modeling studies including cost inputs should critically evaluate the risk of bias based on costing methods and data sources.

Shared (epi)genomic background connecting neurodegenerative diseases and type 2 diabetes

The progressive aging of populations has resulted in an increased prevalence of chronic pathologies, especially of metabolic, neurodegenerative and movement disorders. In particular, type 2 diabetes (T2D), Alzheimer’s disease (AD) and Parkinson’s disease (PD) are among the most prevalent age-related, multifactorial pathologies that deserve particular attention, given their dramatic impact on patient quality of life, their economic and social burden as well the etiopathogenetic mechanisms, which may overlap in some cases. Indeed, the existence of common triggering factors reflects the contribution of mutual genetic, epigenetic and environmental features in the etiopathogenetic mechanisms underlying T2D and AD/PD. On this subject, this review will summarize the shared (epi)genomic features that characterize these complex pathologies. In particular, genetic variants and gene expression profiles associated with T2D and AD/PD will be discussed as possible contributors to determine the susceptibility and progression to these disorders. Moreover, potential shared epigenetic modifications and factors among T2D, AD and PD will also be illustrated. Overall, this review shows that findings from genomic studies still deserves further research to evaluate and identify genetic factors that directly contribute to the shared etiopathogenesis. Moreover, a common epigenetic background still needs to be investigated and characterized. The evidences discussed in this review underline the importance of integrating large-scale (epi)genomic data with additional molecular information and clinical and social background in order to finely dissect the complex etiopathogenic networks that build up the “disease interactome” characterizing T2D, AD and PD.

Emergency Department Visits for Psychotropic-Related Adverse Drug Events in Older Adults With Alzheimer Disease, 2013-2014

Background: More than 1.3 million emergency department visits have been associated with adverse drug events (ADEs) in older adults. Increasing Alzheimer's disease (AD) prevalence in the geriatric population poses an additive risk of ADEs because of the array of psychotropic medications prescribed for AD patients. Scant research has been conducted at a nationwide level on psychotropic-related ADEs in this population. Objective: This study aimed to determine the incidence and economic burden of psychotropic ADEs in the geriatric AD population compared with the non-AD geriatric population. Methods: A retrospective analysis was conducted of geriatric AD patients who visited the ED in 2013 with a psychotropic-related ADE to determine the incidence and resource utilization of these events. The relationship between presence of AD and an ADE was analyzed using multiple logistic regression. Results: There were 427 969 Alzheimer's ED visits compared with 20 492 554 ED visits without. Of the AD cases, 1.04% were associated with at least 1 adverse event. AD cases more frequently were admitted as inpatients (64.90% vs 34.92%, P < 0.01). Common drug classes associated with AD-related ADEs were benzodiazepines, antipsychotics, and autonomic nervous system-affecting agents (adrenergic agonists, antimuscarinic agents, anticholinergic agents). There was a significantly higher likelihood for Alzheimer's cases to experience any psychotropic-related adverse event (OR = 1.66; 95% CI = 1.20, 1.82). Conclusion and Relevance: Alzheimer's patients more frequently experienced psychotropic-related adverse events and related adverse outcomes than older adults without Alzheimer's. Application of these findings should be implemented in protocol development to reduce future psychotropic-related adverse outcomes for this population.

The development of a stochastic mathematical model of Alzheimer's disease to help improve the design of clinical trials of potential treatments

Alzheimer's disease (AD) is a neurodegenerative disorder characterised by a slow progressive deterioration of cognitive capacity. Drugs are urgently needed for the treatment of AD and unfortunately almost all clinical trials of AD drug candidates have failed or been discontinued to date. Mathematical, computational and statistical tools can be employed in the construction of clinical trial simulators to assist in the improvement of trial design and enhance the chances of success of potential new therapies. Based on the analysis of a set of clinical data provided by the Alzheimer's Disease Neuroimaging Initiative (ADNI) we developed a simple stochastic mathematical model to simulate the development and progression of Alzheimer's in a longitudinal cohort study. We show how this modelling framework could be used to assess the effect and the chances of success of hypothetical treatments that are administered at different stages and delay disease development. We demonstrate that the detection of the true efficacy of an AD treatment can be very challenging, even if the treatment is highly effective. An important reason behind the inability to detect signals of efficacy in a clinical trial in this therapy area could be the high between- and within-individual variability in the measurement of diagnostic markers and endpoints, which consequently results in the misdiagnosis of an individual's disease state.

Detection of Plasma Biomarkers Using Immunomagnetic Reduction: A Promising Method for the Early Diagnosis of Alzheimer's Disease

Alzheimer's disease (AD) is the most common form of dementia. The development of assay technologies able to diagnose early-stage AD is important. Blood tests to detect biomarkers, such as amyloid and total Tau protein, are among the most promising diagnostic methods due to their low cost, low risk, and ease of operation. However, such biomarkers in blood occur at extremely low levels and are difficult to detect precisely. In the early 2000s, a highly sensitive assay technology, immunomagnetic reduction (IMR), was developed. IMR involves the use of antibody-functionalized magnetic nanoparticles dispersed in aqueous solution. The concentrations of detected molecules are converted to reductions in the ac magnetic susceptibility of this reagent due to the association between the magnetic nanoparticles and molecules. To achieve ultra-high sensitivity, a high-Tc superconducting-quantum-interference-device (SQUID) ac magnetosusceptometer was designed and applied to detect the tiny reduction in the ac magnetic susceptibility of the reagent. Currently, a 36-channeled high-Tc SQUID-based ac magnetosusceptometer is available. Using the reagent and this analyzer, extremely low concentrations of amyloid and total Tau protein in human plasma could be detected. Further, the feasibility of identifying subjects in early-stage AD via assaying plasma amyloid and total Tau protein is demonstrated. The results show a diagnostic accuracy for prodromal AD higher than 80% and reveal the possibility of screening for early-stage AD using SQUID-based IMR.

The economic burden of the care and treatment for people with Alzheimer's disease: the outlook for the Czech Republic

The aim of this paper is to specify the cost of treatment and care for people with Alzheimer's disease (AD) in the Czech Republic and also with a view to the future. Data availability is evaluated as well as the quality of cost comparison with other developed countries. Data for the Czech Republic will include data from the health insurance company regarding medicines and treatment, as well as a selected home caring for people with dementia and, ultimately, the Social Security Administration. The basic methods include an analysis of data from publicly available sources, direct interviews with the representatives of nursing homes caring for people with dementia and the representative of the Social Security Administration of the Czech Republic. Items will be specified within the category of direct costs. For the study, the indirect costs related to the loss of patient as well as caring person productivity are not considered. Costs for treatment and care are based from the data on 4162 patients, the costs of a bed from data on 391 beds in homes for the elderly. The average annual cost per patient with AD in the Czech Republic was calculated and came to the amount of 12,783 EUR. These items include outpatient care, inpatient care in a medical facility, inpatient care in homes and medications. In terms of share of these items on the direct costs, the largest item are services provided by special homes which contributes to the direct costs by 94 %, medications create 1 % and treatment (both outpatient and inpatient) 5 %. In the case of home care the total costs are lower at 4698 EUR. The Czech Republic as well as other developed countries are faced with the problem of unified accounting cost of people suffering from Alzheimer's disease. This then causes the calculation of the economic burden to be very difficult and indicative values.

The main cost drivers in dementia: a systematic review

OBJECTIVES

Because of the increasing prevalence of dementia worldwide, combined with limited healthcare expenditures, a better understanding of the main cost drivers of dementia in different care settings is needed.

METHODS

A systematic review of cost-of-illness (COI) studies in dementia was conducted from 2003 to 2012, searching the following databases: PubMed (Medline), Cochrane Library, ScienceDirect (Embase) and National Health Service Economic Evaluations Database. Costs (per patient) by care setting were analyzed for total, direct, indirect and informal costs and related to the following: (1) cost perspective and (2) disease severity.

RESULTS

In total, 27 studies from 14 different healthcare systems were evaluated. In the included studies, total annual costs for dementia of up to $70,911 per patient (mixed setting) were estimated (average estimate of total costs = $30,554). The shares of cost categories in the total costs for dementia indicate significant differences for different care settings. Overall main cost drivers of dementia are informal costs due to home based long term care and nursing home expenditures rather than direct medical costs (inpatient and outpatient services, medication).

CONCLUSIONS

The results of this review highlight the significant economic burden of dementia for patients, families and healthcare systems and thus are important for future health policy planning. The significant variation of cost estimates for different care settings underlines the need to understand and address the financial burden of dementia from both perspectives. For health policy planning in dementia, future COI studies should follow a quality standard protocol with clearly defined cost components and separate estimates by care setting and disease severity.

Validation of a self-administered computerized system to detect cognitive impairment in older adults

There is increasing interest in the development of economical and accurate approaches to identifying persons in the community who have mild, undetected cognitive impairments. Computerized assessment systems have been suggested as a viable approach to identifying these persons. The validity of a computerized assessment system for identification of memory and executive deficits in older individuals was evaluated in the current study. Volunteers (N = 235) completed a 3-hr battery of neuropsychological tests and a computerized cognitive assessment system. Participants were classified as impaired (n = 78) or unimpaired (n = 157) on the basis of the Mini Mental State Exam, Wechsler Memory Scale-III and the Trail Making Test (TMT), Part B. All six variables (three memory variables and three executive variables) derived from the computerized assessment differed significantly between groups in the expected direction. There was also evidence of temporal stability and concurrent validity. Application of computerized assessment systems for clinical practice and for identification of research participants is discussed in this article.

The Value of Delaying Alzheimer's Disease Onset

Alzheimer's disease (AD) extracts a heavy societal toll. The value of medical advances that delay onset of AD could be significant. Using data from nationally representative samples from the Health and Retirement Study (1998-2008) and Aging Demographics and Memory Study (2001-2009), we estimate the prevalence and incidence of AD and the formal and informal health care costs associated with it. We use microsimulation to project future prevalence and costs of AD under different treatment scenarios. We find from 2010 to 2050, the number of individuals ages 70+ with AD increases 153%, from 3.6 to 9.1 million, and annual costs increase from $307 billion ($181B formal, $126B informal costs) to $1.5 trillion. 2010 annual per person costs were $71,303 and double by 2050. Medicare and Medicaid are paying 75% of formal costs. Medical advances that delay onset of AD for 5 years result in 41% lower prevalence and 40% lower cost of AD in 2050. For one cohort of older individuals, who would go on to acquire AD, a 5-year delay leads to 2.7 additional life years (about 5 AD-free), slightly higher formal care costs due to longer life but lower informal care costs for a total value of $511,208 per person. We find Medical advances delaying onset of AD generate significant economic and longevity benefits. The findings inform clinicians, policymakers, businesses and the public about the value of prevention, diagnosis, and treatment of AD.

Impacto econômico da doença de Alzheimer no Brasil: é possível melhorar a assistência e reduzir custos?

O objetivo deste estudo foi discutir dados relativos aos custos da Doença de Alzheimer (DA) e as iniciativas assistenciais para reduzir custos e auxiliar a família e os cuidadores no manejo com a doença. O fator de maior custo para as pessoas com DA leve foi o do tempo do cuidador não remunerado, enquanto que para aqueles com a doença em estágio avançado foi o dos cuidados relativos à institucionalização. Frente a esse panorama a literatura propõe a adoção de modelos de atenção que maximizem a independência funcional do idoso e a manutenção de suas habilidades, como a implantação do Centro Dia para Idosos e de programas de reabilitação e amparo ao idoso e família. Esses modelos de atenção precisam ser discutidos, estruturados e implantados na realidade brasileira.

Anxiety and stigma in dementia: a threat to aging in place

The number of Americans with dementia is expected to increase as the population ages. Developing dementia is feared by many older adults and may result in anxiety in persons with dementia. This article focuses on anxiety, one of the least understood symptoms associated with dementia in community-dwelling older adults, the stigma of dementia, and the relationship between anxiety and stigma in dementia. When undetected and untreated, anxiety and associated stigma can adversely affect quality of life and the ability to age in place.

Using U.S. Medicare records to evaluate the indirect health effects on spouses: a case study in Alzheimer's disease patients

BACKGROUND

The burden experienced by spouses of patients with Alzheimer's disease (AD) may have negative consequences for their physical health. We describe here a method for analyzing United States Medicare records to determine the changes in health service use and costs experienced by spouses after their marital partner receives an AD diagnosis.

METHODS

We initially identified all beneficiaries in the 2001-2005 Medicare 5% sample who had multiple claims listing the ICD-9 diagnostic code for AD, 331.0. The 5% sample includes spouses who share a Medicare account with their marital partners because they lack a sufficient work history for full eligibility on their own. A matched cohort study assessed incremental health costs in the spouses of AD patients versus a control group of spouses of non-AD patients. Longitudinal and cross-sectional analyses tracked the impact of a patient's AD diagnosis on his or her spouse's healthcare costs.

RESULTS

Our method located 54,593 AD patients of whom 11.5% had spouses identifiable via a shared Medicare account. AD diagnosis in one member of a couple was associated with significantly higher monthly Medicare payments for the other member's healthcare. The spouses' elevated costs commenced 2 to 3 months before their partners' AD diagnosis and persisted over the follow-up period. After 31 months, the cumulative additional Medicare reimbursements totaled a mean $4,600 in the spouses of AD patients. This excess was significant even after accounting for differences in baseline health status between the cohorts.

CONCLUSION

The study methodology provides a framework for comprehensively evaluating medical costs of both chronically ill patients and their spouses. This method also provides monthly data, which makes possible a longitudinal evaluation of the cost effects of specific health events. The observed correlations provide a coherent demonstration of the interdependence between AD patients' and spouses' health. Future research should examine caregiving burden and other possible factors contributing to the AD spouses' health outcomes. It should also extend the method presented here to evaluations of other chronic diseases of the elderly.

Amyloid beta: multiple mechanisms of toxicity and only some protective effects?

Amyloid beta (Aβ) is a peptide of 39–43 amino acids found in large amounts and forming deposits in the brain tissue of patients with Alzheimer's disease (AD). For this reason, it has been implicated in the pathophysiology of damage observed in this type of dementia. However, the role of Aβ in the pathophysiology of AD is not yet precisely understood. Aβ has been experimentally shown to have a wide range of toxic mechanisms in vivo and in vitro, such as excitotoxicity, mitochondrial alterations, synaptic dysfunction, altered calcium homeostasis, oxidative stress, and so forth. In contrast, Aβ has also shown some interesting neuroprotective and physiological properties under certain experimental conditions, suggesting that both physiological and pathological roles of Aβ may depend on several factors. In this paper, we reviewed both toxic and protective mechanisms of Aβ to further explore what their potential roles could be in the pathophysiology of AD. The complete understanding of such apparently opposed effects will also be an important guide for the therapeutic efforts coming in the future.

Hygiene and the world distribution of Alzheimer's disease: Epidemiological evidence for a relationship between microbial environment and age-adjusted disease burden

People living in sanitized environments may be at greater Alzheimer's risk. We compare Alzheimer's rates in different countries in light of countries' historical and contemporary pathogen prevalence, sanitation, and urbanization. We find that countries that are less urbanized, with more pathogens and lower degree of sanitation have lower Alzheimer's rates.

Background and objectives: Alzheimer’s disease (AD) shares certain etiological features with autoimmunity. Prevalence of autoimmunity varies between populations in accordance with variation in environmental microbial diversity. Exposure to microorganisms may improve individuals’ immunoregulation in ways that protect against autoimmunity, and we suggest that this may also be the case for AD. Here, we investigate whether differences in microbial diversity can explain patterns of age-adjusted AD rates between countries.

Methodology: We use regression models to test whether pathogen prevalence, as a proxy for microbial diversity, across 192 countries can explain a significant amount of the variation in age-standardized AD disability-adjusted life-year (DALY) rates. We also review and assess the relationship between pathogen prevalence and AD rates in different world populations.

Results: Based on our analyses, it appears that hygiene is positively associated with AD risk. Countries with greater degree of sanitation and lower degree of pathogen prevalence have higher age-adjusted AD DALY rates. Countries with greater degree of urbanization and wealth exhibit higher age-adjusted AD DALY rates.

Conclusions and implications: Variation in hygiene may partly explain global patterns in AD rates. Microorganism exposure may be inversely related to AD risk. These results may help predict AD burden in developing countries where microbial diversity is rapidly diminishing. Epidemiological forecasting is important for preparing for future healthcare needs and research prioritization.

Impact of dementia on payments for long-term and acute care in an elderly cohort

BACKGROUND

Older people with dementia have increased risk of nursing home (NH) use and higher Medicaid payments. Dementia's impact on acute care use and Medicare payments is less well understood.

OBJECTIVES

Identify trajectories of incident dementia and NH use, and compare Medicare and Medicaid payments for persons having different trajectories.

RESEARCH DESIGN

Retrospective cohort of older patients who were screened for dementia in 2000-2004 and were tracked for 5 years. Trajectories were identified with latent class growth analysis.

SUBJECTS

A total of 3673 low-income persons aged 65 or older without dementia at baseline.

MEASURES

Incident dementia diagnosis, comorbid conditions, dual eligibility, acute and long-term care use and payments based on Medicare and Medicaid claims, medical record systems, and administrative data.

RESULTS

Three trajectories were identified based on dementia incidence and short-term and long-term NH use: (1) high incidence of dementia with heavy NH use (5% of the cohort) averaging $56,111/year ($36,361 Medicare, $19,749 Medicaid); (2) high incidence of dementia with little or no NH use (16% of the cohort) averaging $16,206/year ($14,644 Medicare, $1562 Medicaid); and (3) low incidence of dementia and little or no NH use (79% of the cohort) averaging $8475/year ($7558 Medicare, $917 Medicaid).

CONCLUSIONS

Dementia and its interaction with NH utilization are major drivers of publicly financed acute and long-term care payments. Medical providers in Accountable Care Organizations and other health care reform efforts must effectively manage dementia care across the care continuum if they are to be financially viable.

The clinical and economic burden of newly diagnosed Alzheimer's disease in a medicare advantage population

BACKGROUND/RATIONALE

Alzheimer's disease (AD) represents a serious public health issue affecting approximately 5.4 million individuals in the United States and is projected to affect up to 16 million by 2050. This study examined health care resource utilization (HCRU), costs, and comorbidity burden immediately preceding new diagnosis of AD and 2 years after diagnosis.

METHODS

This study utilized a claims-based, retrospective cohort design. Medicare Advantage members newly diagnosed with AD (n = 3374) were compared to matched non-AD controls (n = 6748). All patients with AD were required to have 12 months of continuous enrollment prior to AD diagnosis (International Classification of Diseases, Clinical Modification [ICD-9] 331.0), during which time no diagnosis of AD, a related dementia, or an AD medication was observed. Non-AD controls demonstrated no diagnosis of AD, a related dementia, or a prescription claim for an AD medication treatment during their health plan enrollment. Medical and pharmacy claims data were used to measure HCRU, costs, and comorbidity burden over a period of 36 months (12 months pre-diagnosis and 24 months post-diagnosis).

RESULTS

The HCRU and costs were greater for AD members during the year prior to diagnosis and during postdiagnosis years 1 and 2 compared to controls. The AD members also displayed greater comorbidity than their non-AD counterparts during postdiagnosis years 1 and 2, as measured by 2 different comorbidity indices.

CONCLUSIONS

Members newly diagnosed with AD demonstrated greater HCRU, health care costs, and comorbidity burden compared to matched non-AD controls.

Transitions in care for older adults with and without dementia

OBJECTIVES

To describe transitions in care of persons with dementia with attention to nursing facility transitions.

DESIGN

Prospective cohort.

SETTING

Public health system.

PARTICIPANTS

Four thousand one hundred ninety-seven community-dwelling older adults.

MEASUREMENTS

Participants' electronic medical records were merged with Medicare claims, Medicaid claims, the Minimum Data Set (MDS), and the Outcome and Assessment Information Set (OASIS) from 2001 to 2008 with a mean follow-up of 5.2 years from the time of enrollment.

RESULTS

Older adults with prevalent (n = 524) or incident (n = 999) dementia had greater Medicare (44.7% vs 44.8% vs 11.4%, P < .001) and Medicaid (21.0% vs 16.8% vs 1.4%, P < .001) nursing facility use, greater hospital (76.2% vs 86.0% vs 51.2%, P < .001) and home health (55.7% vs 65.2% vs 27.3%, P < .001) use, more transitions in care per person-year of follow-up (2.6 vs 2.7 vs 1.4, P < .001), and more mean total transitions (11.2 vs 9.2 vs 3.8, P < .001) than those who were never diagnosed (n = 2,674). For the 1,523 participants with dementia, 74.5% of transitions to nursing facilities were transfers from hospitals. For transitions from nursing facilities, the conditional probability was 41.0% for a return home without home health care, 10.7% for home health care, and 39.8% for a hospital transfer. Of participants with dementia with a rehospitalization within 30 days, 45% had been discharged to nursing facilities from the index hospitalization. At time of death, 46% of participants with dementia were at home, 35% were in the hospital, and 19% were in a nursing facility.

CONCLUSION

Individuals with dementia live and frequently die in community settings. Nursing facilities are part of a dynamic network of care characterized by frequent transitions.

How does the canadian general public rate moderate Alzheimer's disease?

Objectives. The objectives of this study were to elicit health utility scores for moderate Alzheimer's disease (AD) using members of the general public. Methods. Five-hundred Canadians were chosen randomly to participate in a telephone interview. The EQ-5D was administered to estimate the health utility score for respondents' current health status (i.e., no AD) and for a hypothetical moderate AD health state. Regression analyses were conducted to explain the perceived utility decrement associated with AD. Results. The mean age of the respondents was 51 years, 60% were female, and 42% knew someone with AD. Respondents' mean EQ-5D scores for their current health status and a hypothetical moderate AD were 0.873 (SD: 0.138) and 0.638 (SD: 0.194), respectively (P < 0.001). Age, gender, and education were significant factors explaining this decrement in utility. Conclusion. Members of the general public may serve as an alternative to patients and caregivers in the elicitation of health-related quality of life in AD.

Treatment guidelines for Alzheimer's disease: redefining perceptions in primary care

BACKGROUND

Current treatment guidelines for Alzheimer's disease (AD) do not reflect more recently collected data on therapeutic outcomes other than cognitive function and memory, and this has led to a limited understanding of the value of drug therapy in AD.

OBJECTIVES

To evaluate the need to revise treatment guidelines for AD, to review data that have become available since the publication of current guidelines, and to communicate how existing guidelines and relevant new data can be valuable to the primary care provider who assesses and treats patients with AD.

DATA SOURCES

A MEDLINE search was conducted to identify existing treatment guidelines using the MeSH headings Alzheimer disease-drug therapy AND practice guidelines. The alternative terms treatment guidelines, practice parameter, and practice recommendation were also searched in conjunction with the MeSH term Alzheimer disease-drug therapy. Additionally, MEDLINE was searched using the term dementia and publication type "practice guideline." All searches were limited to articles published within the last 10 years, in English. A total of 116 articles were identified by these searches. Additional publications were identified by manually searching the reference lists of these articles and of published clinical trials of AD therapies.

STUDY SELECTION AND DATA EXTRACTION

Current AD treatment guidelines and clinical trial results for AD treatment options were extracted, reviewed, and summarized to meet the objectives of this article.

DATA SYNTHESIS

Current guidelines support the use of cholinesterase inhibitors in patients with mild to moderate AD. More recent clinical research indicates that cholinesterase inhibitor treatment provides effectiveness across a wide range of dementia severity and multiple symptom domains. These medications also significantly decrease caregiver burden and may lower the risk for nursing home placement.

CONCLUSIONS

The expanding literature on AD medications suggests that treatment guidelines need to be reexamined. Recent data emphasize preservation of abilities and delay of adverse outcomes in AD patients rather than short-term improvements in cognitive test scores. Treatment appears to provide the greatest benefit when it is initiated early in the course of the disease and maintained over the long term. Revised treatment guidelines should address newer medications and more recent outcomes considerations, as well as provide guidance on how long to continue and when to discontinue pharmacotherapy for AD.

Dental X-ray exposure and Alzheimer's disease: a hypothetical etiological association

Despite the fact that Alzheimer's disease was identified more than 100 years ago, its cause remains elusive. Although the chance of developing Alzheimer's disease increases with age, it is not a natural consequence of aging. This article proposes that dental X-rays can damage microglia telomeres - the structures at the end of chromosomes that determine how many times cells divide before they die - causing them to age prematurely. Degenerated microglia lose their neuroprotective properties, resulting in the formation of neurofibrillary tau tangles and consequently, the neuronal death that causes Alzheimer's dementia. The hypothesis that Alzheimer's is caused specifically by microglia telomere damage would explain the delay of one decade or longer between the presence of Alzheimer's brain pathology and symptoms; telomere damage would not cause any change in microglial function, it would just reset the countdown clock so that senescence and apoptosis occurred earlier than they would have without the environmental insult. Once microglia telomere damage causes premature aging and death, the adjacent neurons are deprived of the physical support, maintenance and nourishment they require to survive. This sequence of events would explain why therapies and vaccines that eliminate amyloid plaques have been unsuccessful in stopping dementia. Regardless of whether clearing plaques is beneficial or harmful - which remains a subject of debate - it does not address the failing microglia population. If microglia telomere damage is causing Alzheimer's disease, self-donated bone marrow or dental pulp stem cell transplants could give rise to new microglia populations that would maintain neuronal health while the original resident microglia population died.

A systematic review to assess the policy-making relevance of dementia cost-of-illness studies in the US and Canada

A systematic review of dementia cost-of-illness (COI) studies in the US and Canada was conducted to explore the policy-making relevance of these studies. MEDLINE, CINAHL, EconLit, AMED and the Cochrane Library were searched from inception to March 2010 for English-language COI articles. Content analysis was used to extract common themes about dementia cost from the conclusions of articles that passed title, abstract and full-text screening. These themes informed our exploration of the policy-making relevance of COI studies in dementia. The literature search retrieved 961 articles and data were extracted from 46 articles. All except three articles reported data from the US; 27 articles included Alzheimer's dementia only. Common themes pertained to general observations about dementia cost, cost drivers in dementia, caregiver cost, items that may lower dementia cost, social service cost, Medicare and Medicaid cost, and cost comparisons with other diseases. The common themes suggest policy-oriented research for the future. However, the extracted COI studies were typically not conducted for policy-making purposes and they did not commonly provide prescriptive policy options. Researchers and policy makers need to consider whether the optimal research focus in dementia should be on programme evaluations instead of more COI studies.

Qualitative analysis of therapeutic light effects on global function in Alzheimer's disease

The occurrence of Alzheimer's disease (AD) is growing, with 68% of cases occurring in women. Declines in global function exacerbated by reversal of day-night patterns, disturbed sleep-wake rhythms, and excessive daytime sleepiness make managing AD difficult. In this study, the authors examined the effect and duration of effect of therapeutic light on sleep, rest-activity, and global function in women with AD using mixed methods in a two-group experimental design with repeated measures on one factor. Twenty women with AD were randomized to experimental or control conditions. Blue-green or dim red light was delivered via cap visor in the morning. Results of the qualitative analysis of serial interviews with family and facility caregivers regarding perceived effect of light on global function are presented. Themes emerged in both groups with respect to cognition and psychosocial function. Future studies with larger samples using quantitative measures of global function are warranted to verify findings.

Evidence for three loci modifying age-at-onset of Alzheimer's disease in early-onset PSEN2 families

Families with early-onset Alzheimer's disease (AD) sharing a single PSEN2 mutation exhibit a wide range of age-at-onset, suggesting that modifier loci segregate within these families. While APOE is known to be an age-at-onset modifier, it does not explain all of this variation. We performed a genome scan within nine such families for loci influencing age-at-onset, while simultaneously controlling for variation in the primary PSEN2 mutation (N141I) and APOE. We found significant evidence of linkage between age-at-onset and chromosome 1q23.3 (P < 0.001) when analysis included all families, and to chromosomes 1q23.3 (P < 0.001), 17p13.2 (P = 0.0002), 7q33 (P = 0.017), and 11p14.2 (P = 0.017) in a single large pedigree. Simultaneous analysis of these four chromosomes maintained strong evidence of linkage to chromosomes 1q23.3 and 17p13.2 when all families were analyzed, and to chromosomes 1q23.3, 7q33, and 17p13.2 within the same single pedigree. Inclusion of major gene covariates proved essential to detect these linkage signals, as all linkage signals dissipated when PSEN2 and APOE were excluded from the model. The four chromosomal regions with evidence of linkage all coincide with previous linkage signals, associated SNPs, and/or candidate genes identified in independent AD study populations. This study establishes several candidate regions for further analysis and is consistent with an oligogenic model of AD risk and age-at-onset. More generally, this study also demonstrates the value of searching for modifier loci in existing datasets previously used to identify primary causal variants for complex disease traits.

The effect of alcohol and tobacco consumption, and apolipoprotein E genotype, on the age of onset in Alzheimer's disease

OBJECTIVE

This study examined the association between a history of heavy alcohol use and smoking, presence of the apolipoprotein-E epsilon 4 allele (APOE epsilon4), and age of disease onset in a community dwelling sample of 685 Alzheimer's disease (AD) patients spanning three ethnic groups.

DESIGN

Cross-sectional study of AD patients evaluated at a University-affiliated outpatient memory disorders clinic.

SUBJECTS

A clinic-based cohort of white non-Hispanic (WNH; n = 397), white Hispanic (WH; n = 264), and African-American (AA; n = 24) patients diagnosed with possible or probable AD according to NINCDS-ADRDA diagnostic criteria.

MEASUREMENTS

The age of onset of AD was obtained from a knowledgeable family member. All patients were assessed for APOE genotype. History of alcohol and tobacco consumption prior to the onset of dementia was obtained via an interview with the patient and the primary caregiver. A history of heavy drinking was defined as >2 drinks per day and a history of heavy smoking was defined as > or =1 pack per day.

RESULTS

Presence of an APOE epsilon4 allele, a history of heavy drinking, or a history of heavy smoking were each associated with an earlier onset of AD by 2-3 years. Patients with all three risk factors were likely to be diagnosed with AD nearly 10 years earlier than those with none of the risk factors.

CONCLUSION

The results suggest that APOE epsilon4 and heavy drinking and heavy smoking lower the age of onset for AD in an additive fashion.

Rural African American clergy: an exploration of their attitudes and knowledge of Alzheimer's disease

Rural African American clergy's ability to recognize Alzheimer's Disease (AD) and their capacity to provide support to elders with this illness has been neglected in the literature. Using a mental health literacy framework, the purpose of this research was to explore rural African American clergy knowledge and beliefs of AD. In-depth interviews were conducted with 9 African American clergy who oversaw churches in central Kentucky. Although few had direct experience with providing pastoral care to elders with AD, all clergy were literate and aware of the need for additional training. This study seeks to further clarify the role of African American clergy and their understanding of AD to inform the future development of appropriate interventions and establish better collaborative community treatment relationships.

Cost-of-illness studies of dementia: a systematic review focusing on stage dependency of costs

OBJECTIVE

To review cost-of-illness (COI) studies of dementia from Europe and North America which report costs per patient by disease stage.

METHOD

A systematic literature search was performed in electronic databases. Studies were classified according to important determinants of costs. Results were converted into year 2006 USD-PPP, and summarized as costs for formal and informal care in mild, moderate and severe dementia.

RESULTS

28 studies were evaluated. They used a wide range of methods. Costs more than doubled from mild to severe dementia. Patterns and size of estimated costs depended primarily on study objectives (estimation of total costs-net costs), living arrangements of patients (community-dwelling-institutionalized) and inclusion of informal care.

CONCLUSION

This review is the first to have focused on costs in different stages of dementia. The stage is an important determinant of costs. However, characteristics of individual studies need to be considered, when making use of their results.

Dementia care costs and the patient's quality of life (QoL) in Taiwan: home versus institutional care services

Organizing optimal care for demented older people is a complex health care issue. Controversies of service models for demented patients should be balanced between cost of care, placement, and quality of life (QoL). The main purpose of this study was to explore the optimal model of dementia care in Taiwan by evaluating the care cost, patients' QoL and healthcare settings. Overall, 140 pairs of demented patients and their primary informal caregivers were enrolled (89 community-living and 51 institute-living). Compared to institute-living subjects, community-living subjects were significantly better in cognition, physical function and QoL. The annual direct cost of institutional care was significantly higher than community care (464,193 New Taiwanese Dollar (NTD) vs. 144,047 (NTD), p<0.001), but indirect cost was significantly higher in home care (287,904 NTD vs. 35,665 NTD, p<0.001). The care cost of home care subjects with low physical dependence was significantly lower than institutional care subjects, but the care cost of home care subjects with high physical dependence was significantly higher than institutional care subjects. Physical dependence was the significant determinant of QoL for demented patients in this study. In conclusion, demented patients with low physical dependence may be cared in the communities with support and those who had high physical dependence may be cared in the institutes in terms of the balance of QoL and the care cost.

Private costs almost equal health care costs when intervening in mild Alzheimer's: a cohort study alongside the DAISY trial

Background

Alzheimer's disease is the leading cause of dementia and affects about 25 million people worldwide. Recent studies have evaluated the effect of early interventions for dementia, but few studies have considered private time and transportation costs associated with the intervention. This study assessed the total economic costs associated with a multifaceted intervention for mild Alzheimer's disease, including an estimate of the ratio of public to private costs.

Methods

The study sample comprised 163 dyads of patients and caregivers who received a multifaceted intervention of counselling sessions, courses and informational packages. The typical duration of the intervention was 7 months. A micro-costing approach was applied using prospectively collected data on resource utilisation that included estimates of participant time and transportation. Precision estimates were calculated using a bootstrapping technique and structural uncertainty was assessed with sensitivity analysis.

Results

The direct intervention cost was estimated at EUR 1,070 (95% CI 1,029;1,109). The total cost (including private costs) was estimated at EUR 2,020 (95% CI 1,929;2,106) i.e. the ratio of private to public costs was almost 1:1.

Conclusion

Intervention for mild Alzheimer's disease can be undertaken at a relatively low cost to public funds. However, policy planners should pay attention to the significant private costs associated with an intervention, which may ultimately pose a threat to equity in access to health care.

Trial registration

Current Controlled Trials ISRCTN74848736.

Aging Families and the Demographics of Family Financial Support of Adults With Disabilities

Using data from the 2007 American Community Survey (ACS), the study estimated the degree of family financial support for adult members with disabilities living at home. Using the Internal Revenue Service definition of a “qualifying dependent,” need for financial support was defined in terms ability to financially contribute to one’s own support. Estimates indicated that 32.3% of the family-based population of adults with disabilities needed financial support. Among those meeting the support test, approximately 4 in 10 lived in households where the primary income earner was 60 years or older. Results are discussed in terms of greater attention to the impact of emerging family demographics for policy and assumption of a family perspective in policy making.

Early identification and treatment of Alzheimer's disease: social and fiscal outcomes

BACKGROUND

Alzheimer's disease (AD) is a progressive neurodegenerative disease that places substantial burdens on those who provide support for family members with declining cognitive and functional abilities. Many AD patients eventually require formal long-term care services because of the absence, exhaustion, or inability of family members to provide care. The costs of long-term care, and especially nursing home care, often deplete private financial resources, placing a substantial burden on state Medicaid programs. Current evidence suggests that pharmacological treatments and caregiver interventions can delay entry into nursing homes and potentially reduce Medicaid costs. However, these cost savings are not being realized because many patients with AD are either not diagnosed or diagnosed at late stages of the disease, and have no access to Medicare-funded caregiver support programs.

METHODS AND RESULTS

A Monte Carlo cost-benefit analysis, based on estimates of parameters available in the medical literature, suggests that the early identification and treatment of AD have the potential to result in large, positive net social benefits as well as positive net savings for states and the federal government.

CONCLUSIONS

These findings indicate that the early diagnosis and treatment of AD are not only socially desirable in terms of increasing economic efficiency, but also fiscally attractive from both state and federal perspectives. These findings also suggest that failure to fund effective caregiver interventions may be fiscally unsound.

Israeli lay persons' views on priority-setting criteria for Alzheimer's disease

AIM

The aim of this study was to assess Israeli lay persons' preferences for setting priorities for the care of Alzheimer's disease (AD).

BACKGROUND

As the knowledge about AD accumulates, and especially as more therapeutic and non-therapeutic interventions for its early diagnosis and treatment are developed, health-care costs associated with the disease rise dramatically. Therefore, setting priorities for funding these therapies, as well as other costs associated with AD is becoming an increasingly complex need.

METHODS

A convenience sample of 624 community-dwelling men and women participated in the study (mean age = 49, range = 20-90). Participants were asked how strongly they agreed or disagreed with 18 criteria that would be used to set priorities for the allocation of resources in the area of AD.

RESULTS

High-weight criteria included being a life-threatening condition and the benefit of treatment. Average-weight criteria included the severity of the disease, treatment costs and equity of access. The age of the patient also was highly rated. All other patient-related criteria were rated as low. Value orientations and education were the main variables associated with participants' preferences.

CONCLUSIONS

The lay public seems to endorse a multi-criteria decision process for the allocation of resources in the area of AD. Similar to other diseases--disease-related criteria were highly preferred. These preferences should be compared with those of other stakeholders such as clinicians and policy makers.

African American caregivers

Despite the significance of an early diagnosis of Alzheimer's disease (AD), African Americans are diagnosed in later stages of the disease and present with greater cognitive impairment at the time of diagnosis when compared to Euro-Americans. To this end, there exists a paucity of research on diagnostic pathways among African Americans with dementia. More specifically, few studies have explored help-seeking pathways from the initial manifestation of symptoms until an actual diagnosis of Alzheimer's disease was received from the perspective of African American caregivers. Thus, the present study examined the retrospective experiences of 17 African American caregivers who were given a diagnosis of Alzheimer's disease for a family member with dementia. Participants completed face-to-face semi-structured interviews. Study findings revealed a complex interplay between the patient with dementia, entities that comprise their social support network, and clinicians.

The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited

Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We compared Medicare claims from 1993-2005 to clinical dementia assessments carried out in 2001-2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110% increase in costs for those with dementia as compared to a 68% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia.

Patient dependence and longitudinal changes in costs of care in Alzheimer's disease

BACKGROUND/AIMS

To examine the incremental effect of patients' dependence on others, on cost of medical and nonmedical care, and on informal caregiving hours over time.

METHODS

Data are obtained from 172 patients from the Predictors Study, a large, multicenter cohort of patients with probable Alzheimer disease (AD) followed annually for 4 years in 3 University-based AD centers in the USA. Enrollment required a modified Mini-Mental State Examination score >or=30. We examined the effects of patient dependence (measured by the Dependence Scale, DS) and function (measured by the Blessed Dementia Rating Scale, BDRS) on medical care cost, nonmedical care cost, and informal caregiving time using random effects regression models.

RESULTS

A one-point increase in DS score was associated with a 5.7% increase in medical cost, a 10.5% increase in nonmedical cost, and a 4.1% increase in caregiving time. A one-point increase in BDRS score was associated with a 7.6% increase in medical cost, a 3.9% increase in nonmedical cost and an 8.7% increase in caregiving time.

CONCLUSIONS

Both functional impairment and patient dependence were associated with higher costs of care and caregiving time. Measures of functional impairment and patient dependence provide unique and incremental information on the overall impact of AD on patients and their caregivers.

Dementia and Medicare at life's end

OBJECTIVE

To determine the effect of a diagnosis of Alzheimer's disease or related dementias (ADRD), and the timing of first ADRD diagnosis, on Medicare expenditures at end of life.

DATA SOURCES

Monthly Medicare payment data for the 5 years before death linked to the National Long-Term Care Survey (NLTCS) for decedents between 1996 and 2000 (N=4,899).

DATA EXTRACTION METHODS

Medicare payment data for the 5 years before death were used to compare 5-year and 6-month intervals of expenditures (total and six subcategories of services) for persons with and without a diagnosis of ADRD during the last 5 years of life, controlling for age, gender, race, education, comorbidities, and nursing home status. Covariate matching was used.

PRINCIPAL FINDINGS

On average, ADRD diagnosis was not significantly associated with excess Medicare payments over the last 5 years of life. Regarding the timing of ADRD diagnosis, there were no significant 5-year total expenditure differences for persons diagnosed with dementia more than 1 year before death. Payment differences by 6-month intervals were highly sensitive to timing of ADRD diagnosis, with the highest differences occurring around the time of diagnosis. There were reduced, non-significant, or negative total payment differences after the initial diagnosis for those diagnosed at least 1 year before death. Only those diagnosed with ADRD in the last year of life had significantly higher Medicare payments during the last 12 months of life, primarily for acute care services.

CONCLUSIONS

ADRD has a smaller impact on total Medicare expenditures than previously reported in controlled studies. The significant differences occur primarily around the time of diagnosis. Although rates of dementia are increasing per se, our results suggest that long-term (1+ year) ADRD diagnoses do not contribute to greater total Medicare costs at the end of life.

Measuring perceived stigma in persons with progressive neurological disease

The perceived stigma inherent in progressive neurological diseases, such as Alzheimer's dementia (AD) and Parkinson's Disease (PD), has been under-recognized. The purposes of this pilot study were to examine: (1) the psychometric properties of the Stigma Impact (SIS) and Stigma Experience Scales (SES) when used with persons with AD or PD; and (2) differences in perceived stigma by disease diagnosis. The sample included 26 persons with AD and 14 persons with PD. Findings support the reliability of the total SIS scale for both persons with AD or PD. The four SIS subscales had acceptable reliability when used with persons with PD, while two of the four subscales had adequate reliability when used with persons with AD. Internal consistency reliability of the SES was acceptable in PD sample only. Validity of the total SIS scale and the four subscales was supported through significant correlations with mental status (AD sample only), self-esteem, depression, and personal control. Persons with AD scored higher on the SIS internalized shame subscale and lower on personal control compared to persons with PD. Overall, support was found for the SIS as a reliable and valid measure of perceived stigma in persons with AD or PD. The magnitude of perceived stigma in persons with AD is comparable to or greater than other populations of persons with chronic illness, including cancer and PD.

Economic cost of dementia patients according to the limitation of the activities of daily living in Korea

BACKGROUND

Dementia is expected to become a significant social burden in the future. However, there are few reports that have estimated the total economic cost of dementia, particularly according to the limitation in the activities of daily living (ADL) in Korea.

OBJECTIVES

This study is to analyze the health care expenditures and cost per dementia patient, and estimated the total economic cost of dementia.

METHODS

Caregivers of 609 dementia patients, who were randomly selected from a nationwide claim database of the Korean National Health Insurance Corporation, were interviewed using structured questionnaire in the period of September 2005. The total cost including the direct and indirect costs during a year was calculated. The patients were stratified into three limitation groups according to their ADL score. The cost according to the three limitation groups was analyzed. The national cost of dementia patients was then estimated.

RESULTS

The total cost per dementia patient in Korea was $7,462. The direct and indirect costs were $6,626 and $836 per patient, respectively. The cost increased with increasing degree of limitation in the patient's ADL. Over a 1-year period, the total cost per patient in the low limitation group was lower ($3,698) than that of the moderate ($6,064) and high ($11,428) limitation group.

CONCLUSIONS

This study demonstrates that the direct and indirect costs of dementia are considerately small for patients with lower limitation in their ADL. The total economic cost of dementia per year was estimated to be in the range of 1.3 to 3.3 billion dollars on assumptions in Korea.

Memantine: a review of its use in Alzheimer's disease

Memantine (Ebixa, Axura, Namenda, Akatinol) is a moderate-affinity, uncompetitive, voltage-dependent, NMDA-receptor antagonist with fast on/off kinetics that inhibits excessive calcium influx induced by chronic overstimulation of the NMDA receptor. Memantine is approved in the US and the EU for the treatment of patients with moderate to severe dementia of the Alzheimer's type. In well designed clinical trials, oral memantine, as monotherapy or in addition to a stable dose of acetylcholinesterase inhibitors, was well tolerated during the treatment of mild to severe Alzheimer's disease for up to 52 weeks. Memantine generally modified the progressive symptomatic decline in global status, cognition, function and behaviour exhibited by patients with moderate to severe Alzheimer's disease in four 12- to 28-week trials. In patients with mild to moderate Alzheimer's disease, data from three 24-week trials are equivocal, although meta-analyses indicate beneficial effects on global status and cognition. Memantine is an effective pharmacotherapeutic agent, and currently the only approved option, for the treatment of moderate to severe Alzheimer's disease.

Clinical characteristics and longitudinal changes of informal cost of Alzheimer's disease in the community

Most estimates of the cost of informal caregiving in patients with Alzheimer's disease (AD) remain cross-sectional. Longitudinal estimates of informal caregiving hours and costs are less frequent and are from assessments covering only short periods of time. The objectives of this study were to estimate long-term trajectories of the use and cost of informal caregiving for patients with AD and the effects of patient characteristics on the use and cost of informal caregiving. The sample is drawn from the Predictors Study, a large, multicenter cohort of patients with probable AD, prospectively followed annually for up to 7 years in three university-based AD centers in the United States (n=170). Generalized linear mixed models were used to estimate the effects of patient characteristics on use and cost of informal caregiving. Patients' clinical characteristics included cognitive status (Mini-Mental State Examination), functional capacity (Blessed Dementia Rating Scale (BDRS)), comorbidities, psychotic symptoms, behavioral problems, depressive symptoms, and extrapyramidal signs. Results show that rates of informal care use and caregiving hours (and costs) increased substantially over time but were related differently to patients' characteristics. Use of informal care was significantly associated with worse cognition, worse function, and higher comorbidities. Conditional on receiving informal care, informal caregiving hours (and costs) were mainly associated with worse function. Each additional point on the BDRS increased informal caregiving costs 5.4%. Average annual informal cost was estimated at $25,381 per patient, increasing from $20,589 at baseline to $43,030 in Year 4.

Cognitive assessment and differentiating the 3 Ds (dementia, depression, delirium)

Differentiation between a diminished or altered cognitive functioning asa consequence of aging and one resulting from serious health problems is critical in the elderly. An unrecognized cognitive disorder or the worsening of the impairment may hamper the effectiveness and appropriateness of care and treatment; therefore, standardized assessment procedures and systematic monitoring of cognition and behavior are important aspects of the nursing care. of older adults. In this article, current notions for accurate and comprehensive cognitive assessment in older persons are delineated. Further, an overview of epidemiological screening and diagnostic dilemmas of dementia, depression, and deliriumare provided.