A Comprehensive Measure of the Costs of Caring for a Parent: Differences According to Functional Status

National Estimates of Incremental Work Absenteeism Costs Associated With Adult Children of Parents With Alzheimer's Disease and Related Dementias

OBJECTIVE

More than half of primary caregivers for ADRD patients are adult children, yet there is little empirical evidence on how caring for parents with ADRD affects their employment. Using a nationally representative dataset, this study aimed to estimate incremental work absenteeism costs for adult children of parents with ADRD.

DESIGN, SETTING, AND PARTICIPANTS

The study used the data from the 2015-2021 Medical Expenditure Panel Survey (MEPS). Multivariate regressions and two-part models were employed to estimate the incremental work absenteeism costs among adult children aged 40 to 64 who had at least one parent diagnosed with ADRD, compared with those who did not have ADRD parents.

MEASUREMENTS

The incremental work absenteeism costs due to caregiving for adult children with ADRD parents was a cumulated estimation of labor productivity cost at three stages: (1) the likelihood of not working due to unemployment, (2) the likelihood of missing any workdays for caregiving, and (3) the number of workdays missed due to caregiving.

RESULTS

Adult children with ADRD parents were more likely to be unemployed (OR = 1.80, p = 0.024) and 2.95 times more likely to miss work for caregiving (p = 0.002) than those with non-ADRD parents. The difference in the number of workdays missed for caregiving between children with and without ADRD parents was not significant. The incremental effects of having ADRD parents were estimated to be $4,510.29 ($1,702.09-$6,723.69) per person per year.

CONCLUSIONS

Having ADRD parents significantly increases the chances of unemployment and missing any workdays for caregiving, leading to higher lost labor productivity costs for adult children with ADRD parents.

Long-run consequences of informal elderly care and implications of public long-term care insurance

We estimate a dynamic structural model of labor supply, retirement, and informal caregiving to study short and long-term costs of informal caregiving in Germany. Incorporating labor market frictions and the German tax and benefit system, we find that in the absence of Germany's public long-term insurance scheme, informal elderly care has adverse and persistent effects on labor market outcomes and, thus, negatively affects lifetime earnings and future pension benefits. These consequences of caregiving are heterogeneous and depend on age, previous earnings, and institutional regulations. Policy simulations suggest that while public long-term care insurance policies are fiscally costly and induce negative labor market effects, they can largely offset the personal costs of caregiving and increase welfare, especially for low-income individuals.

Racial and ethnic differences in disease course Medicare expenditures for beneficiaries with dementia

BACKGROUND

Research on racial and ethnic disparities in costs of care during the course of dementia is sparse. We analyzed Medicare expenditures for beneficiaries with dementia to identify when during the course of care costs are the highest and whether they differ by race and ethnicity.

METHODS

We analyzed data from the 2000-2016 Health and Retirement Study (HRS) linked with corresponding Medicare claims to estimate total Medicare expenditures for four phases: (1) the year before a dementia diagnosis, (2) the first year following a dementia diagnosis, (3) ongoing care for dementia after the first year, and (4) the last year of life. We estimated each patient's phase-specific and disease course Medicare expenditures by using a race-specific survival model and monthly expenditures adjusted for patient characteristics. We investigated healthcare utilization by service type across races/ethnicities and phases of care.

RESULTS

Adjusted mean total Medicare expenditures for non-Hispanic (NH) Black ($165,730) and Hispanic beneficiaries with dementia ($160,442) exceeded corresponding expenditures for NH Whites ($136,326). In the year preceding and immediately following initial dementia diagnosis, mean Medicare expenditures for NH Blacks ($26,337 and $20,429) exceeded expenditures for Hispanics and NH Whites ($21,399-23,176 and 17,182-18,244). The last year of life was responsible for the greatest cost contribution: $51,294 (NH Blacks), $47,469 (Hispanics), and $39,499 (NH Whites). These differences were driven by greater use of high-cost services (e.g., emergency department, inpatient and intensive care), especially during the last year of life.

CONCLUSIONS

NH Black and Hispanic beneficiaries with dementia had higher disease course Medicare expenditures than NH Whites. Expenditures were highest for NH Black beneficiaries in every phase of care. Further research should address mechanisms of such disparities and identify methods to improve communication, shared decision-making, and access to appropriate services for all populations.

"It's a stressful, trying time for the caretaker": an interpretive description qualitative study of postoperative transitions in care for older adults with frailty from the perspectives of informal caregivers

BACKGROUND

Older adults with frailty have surgery at a high rate. Informal caregivers often support the postoperative transition in care. Despite the growing need for family and caregiver support for this population, little is known about the experience of providing informal care to older adults with frailty during the postoperative transition in care. The purpose of this study was to explore what is important during a postoperative transition in care for older adults with frailty from the perspective of informal caregivers.

METHODS

This was a qualitative study using an interpretive description methodology. Seven informal caregivers to older adults [aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery] participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using reflexive thematic analysis.

RESULTS

Four themes were constructed: (1) being informed about what to expect after surgery; (2) accessible communication with care providers; (3) homecare resources are needed for the patient; and (4) a support network for the caregivers. Theme 4 included two sub-themes: (a) respite and emotional support and (b) occupational support.

CONCLUSIONS

Transitions in care present challenges for informal caregivers of older adults with frailty, who play an important role in successful transitions. Future postoperative transitional care programs should consider making targeted information, accessible communication, and support networks available for caregivers as part of facilitating successful transitions in care.

Society for Surgery of the Alimentary Tract State-of-the-Art Session 2022: Frailty in Surgery

Given the exponentially aging population and rising life expectancy in the United States, surgeons are facing a challenging frail population who may require surgery but may not qualify based on their general fitness. There is an urgent need for greater awareness of the importance of frailty measurement and the implementation of universal assessment of frail patients into clinical practice. Pairing risk stratification with stringent protocols for prehabilitation and minimally invasive surgery and appropriate enhanced recovery protocols could optimize and condition frail patients before, during, and immediately after surgery to mitigate postoperative complications and consequences on patient function and quality of life. In this paper, highlights from the 2022 Society for Surgery of the Alimentary Tract State-of-the-Art Session on frailty in surgery are presented. This work aims to improve the understanding of the impact of frailty on patients and the methods used to augment the outcomes for frail patients during their surgical experience.

Support for Older Parents in Need in Europe: The Role of the Social Network and of Individual and Relational Characteristics

Background and Objectives

Adult children form the backbone of informal care for older parents. To date, limited attention has been paid to the complex mechanism of providing support to older parents. The present study investigated mezzo- and micro-level correlates of provision of support to older parents. The focus was on the child-parent relationship in childhood and in the present.

Research Design and Methods

Data were derived from the Survey of Health, Ageing and Retirement in Europe (SHARE). The analytic sample comprised respondents who participated in SHARE Waves 6-8 and reported having an unhealthy mother (N = 1,554) or father (N = 478). We used hierarchical logistic regression to address 3 models including individual resources, child-parent characteristics, and social resources. We conducted separate analyses for mothers and fathers.

Results

Providing support to a parent depended primarily on personal resources followed by the quality of the relationship with the parent. A larger social network of the care provider was also related to increased likelihood of providing support. Support to a mother was associated with positive evaluations of the relationship with her in the present and in childhood. At the same time, negative evaluations of the relationship with the father in childhood were negatively related to providing support to him.

Discussion and Implications

The findings point to a multidimensional mechanism, in which adult children's resources are a prominent factor in shaping caregiving behaviors toward their parents. Clinical efforts should focus on adult children's social resources and the quality of the child-parent relationship.

A review of caregiver costs included in cost-of-illness studies

INTRODUCTION

Economic evaluations typically focus solely on patient-specific costs with economic spillovers to informal caregivers less frequently evaluated. This may systematically underestimate the burden resulting from disease.

AREAS COVERED

Cost-of-illness (COI) analyses that identified costs borne to caregiver(s) were identified using PubMed and Embase. We extracted study characteristics, clinical condition, costs, and cost methods. To compare caregiver costs reported across studies, estimated a single 'annual caregiver cost' amount in 2021 USD.

EXPERT OPINION

A total of 51 studies met our search criteria for inclusion with estimates ranging from $30 - $86,543. The majority (63%, 32/51) of studies estimated caregiver time costs with fewer studies reporting productivity or other types of costs. Caregiver costs were frequently reported descriptively (69%, 35/51), with fewer studies reporting more rigorous methods of estimating costs. Only 27% (14/51) of studies included used an incremental analysis approach for caregiver costs. In a subgroup analysis of dementia-focused studies (n = 16), we found the average annual cost of caregiving time for patients with dementia was $30,562, ranging from $4,914 to $86,543. We identified a wide range in annual caregiver cost estimates, even when limiting by condition and cost type.

Out‐of‐pocket costs attributable to dementia: A longitudinal analysis

BACKGROUND

Alzheimer's disease and related dementias (ADRD) affect 5.7 million Americans, and are expensive despite the lack of a cure or even treatments effective in managing the disease. The literature thus far has tended to focus on the costs to Medicare, even though one of the main characteristics of ADRD (the loss of independence and ability to care for oneself) incurs costs not covered by Medicare.

METHODS

In this paper, we use survey data for 2002-2016 from the Health and Retirement Study to estimate the out-of-pocket costs of ADRD for the patient and their family through the first 8 years after the onset of symptoms, as defined by a standardized 27-point scale of cognitive ability. A two-part model developed by Basu and Manning (2010) allows us to separate the costs attributable to ADRD into two components, one driven by differences in longevity and one driven by differences in utilization.

RESULTS

We identified a cohort of 3619 incident dementia cases, 38.9% were male, and 66.9% were non-Hispanic White. Dementia onset was 77.7 years of age, on average. OOP costs attributable to dementia are $8751 over the first 8 years after the onset. These incremental costs are driven by nursing home expenditures, which are largely uninsured in the US. OOP spending is highest for whites and women.

CONCLUSION

The financial burden of ADRD is significant, and largely attributable to the lack of wide-spread long-term care insurance.

Reimagining Financing and Payment of Long-Term Care

The COVID-19 pandemic revealed fundamental problems with the structure of long-term care financing and payment in the United States. The piecemeal system that exists suffers from several key problems, including underfunding, fragmentation across types and sites of care, and substantial variation in payment across states and populations. These problems result in inefficient allocation of resources, limited access to care, substandard quality, and inequities in both access and quality. We propose a new federal benefit for long-term care, most likely as part of the Medicare program. Essential features of this benefit include taxpayer subsidies, along the lines of other Medicare benefits, and coverage across the range of long-term care services, including both residential and home- and community-based care. A new federal benefit has the most potential to break down administrative barriers and improve resource allocation, to ensure adequate payment rates across all states, to expand access to care by spreading risk across the entire Medicare population, and to improve equity by extending coverage to all Medicare beneficiaries who want it. A new federal benefit is politically challenging, requiring bold action by Congress, and entails the risks of administrative challenges and unintended consequences. However, in this case, retaining the status quo remains the far greater risk.

Patient perspectives on states worse than death: A qualitative study with implications for patient-centered outcomes and values elicitation

BACKGROUND

Seriously ill patients rate several health outcomes as states worse than death. It is unclear what factors underlie such valuations, and whether consideration of such states is useful when making medical decisions.

AIM

We sought to (1) use qualitative approaches to identify states worse than death, (2) identify attributes common to such undesirable health states, and (3) determine how participants might use information on these states in making medical decisions.

DESIGN

Qualitative study of semi-structured interviews utilizing content analysis with constant comparison techniques.

SETTING, PARTICIPANTS

We interviewed adults age 65 or older with serious illnesses after discharge home from one of two urban, academic hospitals. Eligible patients were purposively sampled to achieve balance in gender and race.

RESULTS

Of 29 participants, 15 (52%) were female, and 15 were white (52%), with a median age of 72 (interquartile range 69, 75). Various physical, cognitive, and social impairments were identified as states worse than death. The most commonly reported attributes underlying states worse than death were perceived burden on loved ones and inability to maintain human connection. Patients believed information on states worse than death must be individualized, and were concerned their opinions could change with time and fluctuations in health status.

CONCLUSIONS

Common factors underlying undesirable states suggest that for care to be patient-centered it must also be family-centered. Patients' views on using states worse than death in decision making highlight barriers to using avoidance of such states as a quality measure, but also suggest opportunities for eliciting patients' values.

Voluntary Registries to Support Improved Interaction Between Police and People Living with Dementia

This paper provides an overview of the societal impact of a rising dementia population and examines the legal and ethical implications posed by voluntary registries as a community-oriented solution to improve interactions between law enforcement and individuals with dementia. It provides a survey of active voluntary registries across the United States, with a focus on Arizona, which has the highest projected growth for individuals living with dementia in the country.

Impact of dementia: Health disparities, population trends, care interventions, and economic costs

INTRODUCTION

The dementia experience is not a monolithic phenomenon-and while core elements of dementia are considered universal-people living with dementia experience the disorder differently. Understanding the patterning of Alzheimer's disease and related dementias (ADRD) in the population with regards to incidence, risk factors, impacts on dementia care, and economic costs associated with ADRD can provide clues to target risk and protective factors for all populations as well as addressing health disparities.

METHODS

We discuss information presented at the 2020 National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers, Theme 1: Impact of Dementia. In this article, we describe select population trends, care interventions, and economic impacts, health disparities and implications for future research from the perspective of our diverse panel comprised of academic stakeholders, and persons living with dementia, and care partners.

RESULTS

Dementia incidence is decreasing yet the advances in population health are uneven. Studies examining the educational, geographic and race/ethnic distribution of ADRD have identified clear disparities. Disparities in health and healthcare may be amplified by significant gaps in the evidence base for pharmacological and non-pharmacological interventions. The economic costs for persons living with dementia and the value of family care partners' time are high, and may persist into future generations.

CONCLUSIONS

Significant research gaps remain. Ensuring that ADRD healthcare services and long-term care services and supports are accessible, affordable, and effective for all segments of our population is essential for health equity. Policy-level interventions are in short supply to redress broad unmet needs and systemic sources of disparities. Whole of society challenges demand research producing whole of society solutions. The urgency, complexity, and scale merit a "whole of government" approach involving collaboration across numerous federal agencies.

ADL-dependent older adults were identified in medico-administrative databases

OBJECTIVE

We aimed to develop an algorithm for the identification of basic Activities of Daily Living (ADL)-dependency in health insurance databases.

STUDY DESIGN AND SETTING

We used the AMI (Aging Multidisciplinary Investigation) population-based cohort including both individual face-to-face assessment of ADL-dependency and merged health insurance data. The health insurance factors associated with ADL-dependency were identified using a LASSO logistic regression model in 1000 bootstrap samples. An external validation on a 1/97 representative sample of the French Health Insurance general population of Affiliates has been performed.

RESULTS

Among 995 participants of the AMI cohort aged ≥ 65y, 114 (11.5%) were ADL-dependent according to neuropsychologists individual assessments. The final algorithm developed included: age, sex, four drug classes (dopaminergic antiparkinson drugs, antidepressants, antidiabetic agents, lipid modifying agents), three type of medical devices (medical bed, patient lifter, incontinence equipment), four medical acts (GP's consultations at home, daily and non-daily nursing at home, transport by ambulance) and four long-term diseases (stroke, heart failure, coronary heart disease, Alzheimer and other dementia). Applying this algorithm, the estimated prevalence of ADL-dependency was 12.3% in AMI and 9.5% in the validation sample.

CONCLUSION

This study proposes a useful algorithm to identify ADL-dependency in the health insurance data.

Chronic Care, Dementia Care Management, and Financial Considerations

The needs of persons living with Alzheimer's disease and Alzheimer's disease-related dementia (AD/ADRD) are challenged by tremendous complexity impacting both care delivery and financing. Most persons living with dementia (PLWD) also suffer from other chronic medical or mental health conditions, which further burden quality of life and function. In addition to difficult treatment choices, optimal dementia care models likely involve people and services that are not typical pieces of the health care delivery system but are all critical partners-care partners, social workers, and community services, to name a few. More than 200 models of dementia care have demonstrated some efficacy. However, these successful interventions that might address much of the care needed by PLWD are uninsured in the United States, where insurance coverage has focused on acute care needs. This poses great difficulties for both care provision and care financing. In this article, we review these 3 key challenges: dementia care for those with chronic comorbid disease; care models that require people who are not typical providers in traditional care delivery systems; and the mandate to provide high-quality care that is currently not funded by usual health care insurance. We propose promising next steps that could substantially improve the lives of PLWD and the lives of their care partners, and highlight some of the many research questions that remain.

Using Mind Mapping in Family Meetings to Support Shared Decision Making with Pediatric and Geriatric Patients

INTRODUCTION

Divergent objectives and narratives among members of a healthcare team may lead to suffering, underscoring the need to align patient care with the patient's self-identified priorities and goals. Shared decision making (SDM) with patients who may not be able to make healthcare decisions for themselves presents a unique challenge to healthcare providers, caregivers, and patients. Children and the elderly are two such groups where substituted decision making is often required. Family meetings, wherein stakeholders in a patient's care are gathered, present opportunities to align expectations and clinical goals. There is a clear need for a technique exploring all facets of the patient's story within the context of the biopsychosocial-spiritual model. We sought to promote narrative equity among stakeholders and maintain patient focus during family meetings. We describe the use of Mind Mapping in the family meeting to meet these objectives.

METHODS

Using two clinical scenarios, one involving a geriatric patient and another involving a pediatric patient, we describe the stepwise development of Mind Maps and how their use informed discussions among stakeholders in the family meeting.

RESULTS

Stakeholders found the Mind Maps easy to draw and helpful in eliciting their own priorities and preferences. Group exploration and refinement of the Mind Maps helped stakeholders to appreciate others' sometimes divergent perspectives, to ensure that the patient's voice was heard, and to ensure that care decisions were patient focused.

DISCUSSION

Mind Mapping was easily performed in two clinical scenarios, allowing the patient, family, and medical team to explore the biopsychosocial-spiritual model extensively, to appreciate each stakeholder's priorities, and to identify areas for further development. We have found that Mind Mapping helps define the 'topography' of relationships, prioritizes team discussions, finds shared interests in seemingly divergent objectives, and identifies which team member may best lead a discussion on a particular topic.

CONCLUSION

Mind Mapping may be a useful tool for family meetings, particularly for geriatric and pediatric patients with multiple stakeholders involved.

Depression and Change in Caregiver Burden Among Family Members of Intensive Care Unit Survivors

BACKGROUND

Family members of patients in intensive care units may experience psychological distress and substantial caregiver burden.

OBJECTIVE

To evaluate whether change in caregiver burden from intensive care unit admission to 3-month follow-up is associated with caregiver depression at 3 months.

METHODS

Caregiver burden was assessed at enrollment and 3 months later, and caregiver depression was assessed at 3 months. Depression was measured with the Hospital Anxiety and Depression Score. The primary analysis was the association between depression at 3 months and change in caregiver burden, controlling for a history of caregiver depression.

RESULTS

One hundred one participants were enrolled; 65 participants had a surviving loved one and completed 3-month follow-up. At 3-month follow-up, 12% of participants met criteria for depression. Increased caregiver burden over time was significantly associated with depression at follow-up (Fisher exact test, P = .004), although this association was not significant after controlling for self-reported history of depression at baseline (Cochran-Mantel-Haenszel test, P = .23).

CONCLUSIONS

Family members are increasingly recognized as a vulnerable population susceptible to negative psychological outcomes after a loved one's admission to the intensive care unit. In this small sample, no significant association was found between change in caregiver burden and depression at 3 months after controlling for baseline depression.

Physical Rehabilitation Needs in the BRICS Nations from 1990 to 2017: Cross-National Analyses Using Data from the Global Burden of Disease Study

Background: This study analyzes the current and evolving physical rehabilitation needs of BRICS nations (Brazil, Russian Federation, India, China, South Africa), a coalition of large emergent economies increasingly important for global health. Methods: Secondary, cross-national analyses of data on Years Lived with Disability (YLDs) were extracted from the Global Burden of Disease Study 2017. Total physical rehabilitation needs, and those stratified per major condition groups are analyzed for the year 2017 (current needs), and for every year since 1990 (evolution over time). ANOVAs are used to detect significant yearly changes. Results: Total physical rehabilitation needs have increased significantly from 1990 to 2017 in each of the BRICS nations, in every metric analyzed (YLD Counts, YLDs per 100,000 people, and percentage of YLDs relevant to physical rehabilitation; all p < 0.01). Musculoskeletal & pain conditions were leading cause of physical rehabilitation needs across the BRICS nations but to varying degrees: from 36% in South Africa to 60% in Brazil. Country-specific trends include: 25% of South African needs were from HIV-related conditions (no other BRICS nation had more than 1%); India had both absolute and relative growths of pediatric rehabilitation needs (p < 0.01); China had an exponential growth in the per-capita needs from neurological and neoplastic conditions (p < 0.01; r2 = 0.97); Brazil had a both absolute and relative growth of needs coming from musculoskeletal & pain conditions (p < 0.01); and the Russian Federation had the highest neurological rehabilitation needs per capita in 2017 (over than three times those of India, South Africa or Brazil). Conclusions: total physical rehabilitation needs have been increasing in each of the BRICS nations, both in absolute and relative values. Apart from the common growing trend, each of the BRICS nations had own patterns for the amount, typology, and evolution of their physical rehabilitation needs, which must be taken into account while planning for health and physical rehabilitation programs, policies and resources.

The cyclicality of informal care

This paper measures the cyclicality of an important input into elderly health: informal care. Using independent survey measures of informal caregiving and care receipt over the past two decades, we find that informal care from adult children to their elderly parents is countercyclical. By contrast, informal care from spouses is procyclical among individuals in their sixties. We find little corresponding change in the use of formal care, highlighting the potential for unmet care needs across the business cycle. These findings suggest that informal health inputs may play an important role in the interpretation of the cyclicality of elderly mortality.

Aligning use of intensive care with patient values in the USA: past, present, and future

For more than three decades, both medical professionals and the public have worried that many patients receive non-beneficial care in US intensive care units during their final months of life. Some of these patients wish to avoid severe cognitive and physical impairments, and protracted deaths in the hospital setting. Recognising when intensive care will not restore a person's health, and helping patients and families embrace goals related to symptom relief, interpersonal connection, or spiritual fulfilment are central challenges of critical care practice in the USA. We review trials from the past decade of interventions designed to address these challenges, and present reasons why evaluating, comparing, and implementing these interventions have been difficult. Careful scrutiny of the design and interpretation of past trials can show why improving goal concordant care has been so elusive, and suggest new directions for the next generation of research.

What is the marginal benefit of payment-induced family care? Impact on Medicaid spending and health of care recipients

Research on home-based long-term care has centered almost solely on the costs; there has been very little, if any, attention paid to the relative benefits. This study exploits the randomization built into the Cash and Counseling Demonstration and Evaluation program that directly impacted the likelihood of having family involved in home care delivery. Randomization in the trial is used as an instrumental variable for family involvement in care, resulting in a causal estimate of the effect of changing the combination of home health-care providers on health-care utilization and health outcomes of the beneficiary. We find that some family involvement in home-based care significantly decreases health-care utilization: lower likelihood of emergency room use, Medicaid-financed inpatient days, any Medicaid hospital expenditures, and fewer months with Medicaid-paid inpatient use. We find that individuals who have some family involved in home-based care are less likely to have several adverse health outcomes within the first 9 months of the trial, including lower prevalence of infections, bedsores, or shortness of breath, suggesting that the lower utilization may be due to better health outcomes.