Misidentification of Dementia in Medicare Claims and Related Costs

Dying with dementia in nursing homes: A population-based study of decedents and their families

BACKGROUND

Families play a critical role in end-of-life (EOL) care for nursing home (NH) residents with dementia. Despite the important role of family, little is known about the availability and characteristics of families of persons with dementia who die in NHs.

METHODS

This is a retrospective cohort study of 18,339 individuals 65 years and older with dementia who died in a Utah NH between 1998 and 2016, linked to their first-degree family (FDF) members (n = 52,566; spouses = 11.3%; children = 58.3%; siblings = 30.3%). Descriptive statistics, chi-square tests, and t-tests were used to describe the study cohort and their FDF members and to compare sociodemographic and death characteristics of NH decedents with (n = 14,398; 78.5%) and without FDF (n = 3941; 21.5%).

RESULTS

Compared with NH decedents with FDF, NH decedents with dementia without FDF members were more likely to be older (mean age 86.5 vs 85.5), female (70.5% vs 59.3%), non-White/Hispanic (9.9% vs 3.2%), divorced/separated/widowed (84.4% vs 61.1%), less educated (<12th grade; 42.2% vs 33.7%), have Medicare and Medicaid (20.8% vs 12.5%), and die in a rural/frontier NH (25.0% vs 23.4%). NH decedents who did not have FDF were also more likely to die from cancer (4.2% vs 3.9%), chronic obstructive pulmonary disease (COPD; 3.9% vs 2.5%), and dementia (40.5% vs 38.4%) and were less likely to have 2+ inpatient hospitalizations at EOL (13.9% vs 16.2%), compared with NH decedents with FDF.

CONCLUSIONS

Findings highlight differences in social determinants of health (e.g., sex, race, marital status, education, insurance, rurality) between NH decedents with dementia who do and do not have FDF-factors that may influence equity in EOL care. Understanding the role of family availability and familial characteristics on EOL care outcomes for NH residents with dementia is an important next step to informing NH dementia care interventions and health policies.

Attention-Deficit/Hyperactivity Disorder as a Potential Risk Factor for Dementia and Other Neurocognitive Disorders: A Systematic Review

Background

Attention-deficit/hyperactivity disorder (ADHD), a common neurodevelopmental condition now recognized to persist into older adulthood, has been postulated to be a risk factor for neurocognitive disorders given the overlap in clinical features and neurobiology, as well as the complex interplay between ADHD and known risk factors for dementia. Studies have emerged assessing this relationship, but there has not yet been a comprehensive systematic review addressing this topic.

Objective

To assess whether ADHD is a risk factor for neurocognitive disorders and to explore possible mechanisms for such an association.

Methods

A systematic review of the literature was conducted using Medline, Embase, and PsycINFO from inception until June 4, 2023. Studies were included if they assessed whether or how ADHD may be a risk factor for neurocognitive disorders. Studies were excluded if they were not primary literature, not published in a peer-reviewed journal, not in English, and/or used non-human subjects. Study quality was assessed using the QualSyst tool.

Results

Sixteen studies met inclusion criteria. Seven studies found a positive association between ADHD and neurocognitive disorders (all-cause dementia in four studies, Alzheimer's disease in three studies, Lewy body dementia in two studies, and mild cognitive impairment in one study). Four studies did not find an association. Five studies pertained to possible mechanisms for an association, including genetics, with minimal significant findings.

Conclusions

ADHD may be a risk factor for certain neurocognitive disorders, although the evidence base is limited, and the absolute risk is small. Possible explanations include genetic and lifestyle factors.

Association of neurocognitive disorders with morbidity and mortality in older adults undergoing major surgery in the USA: a retrospective, population-based, cohort study

BACKGROUND

Neurocognitive disorders become increasingly common as patients age, and increasing numbers of surgical interventions are done on older patients. The aim of this study was to understand the clinical characteristics and outcomes of surgical patients with neurocognitive disorders in the USA in order to guide future targeted interventions for better care.

METHODS

This retrospective cohort study used claims data for US Medicare beneficiaries aged 65 years and older with a record of inpatient admission for a major diagnostic or therapeutic surgical procedure between Jan 1, 2017, and Dec 31, 2018. Data were retrieved through a data use agreement between Dartmouth Hitchcock Medical Center and US Centers for Medicare and Medicaid Services via the Research Data Assistance Center. The exposure of interest was the presence of a pre-existing neurocognitive disorder as defined by diagnostic code within 3 years of index hospital admission. The primary outcome was mortality at 30 days, 90 days, and 365 days from date of surgery among all patients with available data.

FINDINGS

Among 5 263 264 Medicare patients who underwent a major surgical procedure, 767 830 (14·59%) had a pre-existing neurocognitive disorder and 4 495 434 (85·41%) had no pre-existing neurocognitive disorder. Adjusting for demographic factors and comorbidities, patients with a neurocognitive disorder had higher 30-day (hazard ratio 1·24 [95% CI 1·23-1·25]; p<0·0001), 90-day (1·25 [1·24-1·26]; p<0·0001), and 365-day mortality (1·25 [1·25-1·26]; p<0·0001) compared with patients without a neurocognitive disorder.

INTERPRETATION

Our findings suggest that the presence of a neurocognitive disorder is independently associated with an increased risk of mortality. Identification of a neurocognitive disorder before surgery can help clinicians to better disclose risks and plan for patient care after hospital discharge.

FUNDING

Department of Anesthesiology and Perioperative Medicine at Dartmouth Hitchcock Medical Center.

The disproportionate burden of Alzheimer's disease and related dementias (ADRD) in diverse older adults diagnosed with cancer

INTRODUCTION

Older adults living with Alzheimer's disease and related dementias (ADRD) who are then diagnosed with cancer are an understudied population. While the role of cognitive impairment during and after cancer treatment have been well-studied, less is understood about patients who are living with ADRD and then develop cancer. The purpose of this study is to contribute evidence about our understanding of this vulnerable population.

MATERIALS AND METHODS

This was a retrospective cohort study of a linked, representative family of databases of cancer registries and Medicare administrative claims that make up the SEER-Medicare database. Older adults ages 68 and older with a first primary cancer type: breast, cervical, colorectal, lung, oral, or prostate were eligible for inclusion (N = 337,932). Prevalence estimates of ADRD across cancer types and a 5% non-cancer comparison sample were compared by patient factors.

RESULTS

The overall prevalence of patients who had an ADRD diagnosis anytime in the three years prior to their cancer diagnosis was 5.6%. Patients with ADRD were more likely to be female, older (over age 75), a racial/ethnic minority, single, with multiple chronic conditions, and a tumor diagnosed early (stage I) or were unstaged. Black patients with colorectal and oral cancer had the highest and second highest prevalence of ADRD compared to White patients (13.46% vs 7.95% and 12.64% vs 7.82% respectively, p < .0001). We observed the highest prevalence of ADRD among Black patients for breast (11.85%), cervical (11.98%), lung (8.41%), prostate (4.83), and the 5% sample (9.50%, p > .0001).

DISCUSSION

The higher prevalence of ADRD among Black and Latine older adults with cancer not only aligns with the trend observed in our non-cancer comparison sample, but also, these findings demonstrate the compounded risk experienced by minoritized older adults over the life course. The greater than expected prevalence of patients with ADRD who go on to develop cancer demonstrates better assessment of cognition is urgently needed. Accurate identification of these vulnerable populations is critical to improve assessment, care coordination, and address inequities in screening and treatment planning.

Comparing Dementia Classification by Self-Report and Administrative Records in the National Core Indicators-Aging and Disability Survey: A Predictive Modeling Approach

Policymakers are interested in the long-term services and supports (LTSS) needs of people living with dementia. The National Core Indicators-Aging and Disability (NCI-AD) survey is conducted to evaluate LTSS care needs. However, dementia reporting in NCI-AD varies across states, and is either obtained from state administrative records or self-reported during the survey. We explored the implications of identifying dementia from administrative records versus self-report. We analyzed 24,569 NCI-AD respondents age 65+, of which 22.4% had dementia. To assess dementia accuracy by data source, we fit separate logistic regression models using the administrative and self-reported subsamples. We applied model coefficients to the population whose dementia status came from the opposite source. Using the administrative model to predict self-reported dementia resulted in higher sensitivity than using the self-report model to predict administrative dementia (43.8% vs. 37.9%). The self-report model's diminished sensitivity suggests administrative records may capture cases of dementia missed by self-report.

Advanced practice clinician care and end-of-life outcomes for community- and nursing home-dwelling Medicare beneficiaries with dementia

INTRODUCTION

Older adults with Alzheimer's disease and related dementias (ADRD) often face burdensome end-of-life care transfers. Advanced practice clinicians (APCs)-which include nurse practitioners and physician assistants-increasingly provide primary care to this population. To fill current gaps in the literature, we measured the association between APC involvement in end-of-life care versus hospice utilization and hospitalization for older adults with ADRD.

METHODS

Using Medicare data, we identified nursing home- (N=517,490) and community-dwelling (N=322,461) beneficiaries with ADRD who died between 2016 and 2018. We employed propensity score-weighted regression methods to examine the association between different levels of APC care during their final 9 months of life versus hospice utilization and hospitalization during their final month.

RESULTS

For both nursing home- and community-dwelling beneficiaries, higher APC care involvement associated with lower hospitalization rates and higher hospice rates.

DISCUSSION

APCs are an important group of providers delivering end-of-life primary care to individuals with ADRD.

HIGHLIGHTS

For both nursing home- and community-dwelling Medicare beneficiaries with ADRD, adjusted hospitalization rates were lower and hospice rates were higher for individuals with higher proportions of APC care involvement during their final 9 months of life. Associations between APC care involvement and both adjusted hospitalization rates and adjusted hospice rates persisted when accounting for primary care visit volume.

Optimal Approach for Assessing Evidence of Dementia for Research Studies

The purpose of this study was to describe a process to determine the presence of dementia and test the psychometric properties of the proposed measurement model for dementia. The model included the AD8, the Functional Activities Questionnaire, the Clinical Dementia Rating Scale, and the Saint Louis University Mental Status Examination. A total of 346 patients consented and 176 of those were determined to be eligible as a result of screening with this measurement model. The mean age of the participants was 80.70 (SD = 9.60) and the majority were female (64%), white (66%), not Latinx (99%), and not married (67%). There was evidence of reliability based on the internal consistency of the items on all measures and the limited error associated with each item. There was evidence of construct validity based on model fit. All four measures are recommended as a pragmatic way in which to comprehensively determine evidence of dementia for research studies.

Hospitalizations and Emergency Room Admissions by Mexican American Older Adults with and without Dementia and Caregiver Mental Health

BACKGROUND

Evidence from predominately non-Hispanic White populations indicates that emergency room (ER) admissions and hospitalizations by older adults with and without dementia are associated with caregiver stress and depressive symptoms. These results may not generalize to Hispanic populations because of cultural differences in caregiving roles, responsibilities, and perspectives about care burden.

OBJECTIVE

Investigate the association between ER admissions and hospitalizations by Mexican American older adults with and without dementia and symptoms of depression and stress among family caregivers.

METHODS

Data came from the 2010/11 wave of the Hispanic Established Populations for the Epidemiologic Study of the Elderly and Medicare claims files. The final sample included 326 older adults and their caregivers. Negative binomial regression was used to model the association between hospitalizations and ER admissions by older adults in the previous two years and caregivers' depressive symptoms and stress in 2010/11.

RESULTS

The number of older adult ER admissions and hospitalizations was not associated with caregiver depressive symptoms. Two or more ER admissions (incident rate ratio [IRR] = 1.26, 95% CI = 1.05-1.51) and two or more hospitalizations (IRR = 1.32, 95% CI = 1.07-1.61) were associated with significantly higher caregiver stress. Additionally, ER admissions and hospitalizations for a circulatory disease or injury and poisoning were associated with significantly higher caregiver stress. These associations were not modified by the care recipient's dementia status.

CONCLUSION

Hospitalizations and ER admissions by older Mexican Americans were associated with greater caregiver stress but not depressive symptoms. These associations were similar for caregivers to older adults with and without dementia.

Racial/Ethnic Disparities in Misidentification of Dementia in Medicare Claims: Results from the Washington Heights-Inwood Columbia Aging Project

BACKGROUND

Misidentification of dementia in Medicare claims is quite common.

OBJECTIVE

We examined potential race/ethnic disparities in misidentification of dementia in Medicare claims in a diverse cohort of older adults who underwent careful clinical assessment.

METHODS

Participants were enrolled in the Washington Heights-Inwood Columbia Aging Project (WHICAP), a multiethnic, population-based, prospective study of cognitive aging in which dementia status was assessed using a rigorous clinical protocol. ICD-9-CM and ICD-10-CM diagnosis codes in all available Medicare claims (1999-2019) were compared to clinical dementia diagnosis and categorized into three mutually exclusive groups: 1) congruent-, 2) over-, and 3) under- identification during the study period. Multinomial logistic regression model was used to examine the relationship between race (White, African American/Black, other) and ethnicity (Hispanic/Latinx, non-Hispanic/Latinx) and congruency of dementia identification after controlling for clinical (cognition, function, comorbidities) and demographic characteristics (age, sex, education), and inpatient and outpatient utilization.

RESULTS

Across all person-years, 88.4% had congruent identification of dementia compared to clinical diagnosis, in 4.1% of the times participants were over-identified with dementia, and 7.5% of the times the participants were under-identified. Rates of misidentification was higher in minority participants than in White, non-Hispanic participants. Multivariable estimation results showed that the probability of over-identification with dementia was 2.2% higher for African American/Black than White (p = 0.05) and 2.7% higher for Hispanic participants than non-Hispanics (p = 0.03) participants. Differences in under-identification by race/ethnicity were not statistically significant.

CONCLUSIONS

African American/Black and Hispanic participants were more likely over-identified with dementia in Medicare claims.

Code-Based Algorithms for Identifying Dementia in Electronic Health Records: Bridging the Gap Between Theory and Practice

Code-based algorithms are crucial tools in the detection of dementia using electronic health record data, with broad applications in medical research and healthcare. Vassilaki et al.'s study explores the efficacy of code-based algorithms in dementia detection using electronic health record data, achieving approximately 70% sensitivity and positive predictive value. Despite the promising results, the algorithms fail to detect around 30% of dementia cases, highlighting challenges in distinguishing cognitive decline factors. The study emphasizes the need for algorithmic improvements and further exploration across diverse healthcare systems and populations, serving as a critical step toward bridging gaps in dementia care and understanding.

Blood Biomarkers for the Diagnosis of Neurodegenerative Dementia: A Systematic Review

IMPORTANCE

Accurately diagnosing neurodegenerative dementia is often challenging due to overlapping clinical features. Disease specific biomarkers could enhance diagnostic accuracy. However, CSF analysis procedures and advanced imaging modalities are either invasive or high-priced, and routinely unavailable. Easily accessible disease biomarkers would be of utmost value for accurate differential diagnosis of dementia subtypes.

OBJECTIVE

To assess the diagnostic accuracy of blood-based biomarkers for the differential diagnosis of AD from Frontotemporal Lobar Degeneration (FTLD), or AD from Dementia with Lewy Bodies (DLB).

METHODS

Systematic review. Three databases (PubMed, Scopus, and Web of Science) were searched. Studies assessing blood-based biomarkers levels in AD versus FTLD, or AD versus DLB, and its diagnostic accuracy, were selected. When the same biomarker was assessed in three or more studies, a meta-analysis was performed. QUADAS-2 criteria were used for quality assessment.

RESULTS

Twenty studies were included in this analysis. Collectively, 905 AD patients were compared to 1262 FTLD patients, and 209 AD patients were compared to 246 DLB patients. Regarding biomarkers for AD versus FTLD, excellent discriminative accuracy (AUC >0.9) was found for p-tau181, p-tau217, synaptophysin, synaptopodin, GAP43 and calmodulin. Other biomarkers also demonstrated good accuracy (AUC = 0.8-0.9). For AD versus DLB distinction, only miR-21-5p and miR-451a achieved excellent accuracy (AUC >0.9).

CONCLUSION

Encouraging results were found for several biomarkers, alone or in combination. Prospective longitudinal designs and consensual protocols, comprising larger cohorts and homogeneous testing modalities across centres, are essential to validate the clinical value of blood biomarkers for the precise etiological diagnosis of dementia.

The costs of treating all-cause dementia among American Indians and Alaska native adults who access services through the Indian Health Service and Tribal health programs

INTRODUCTION

Little is known about treatment costs for American Indian and Alaska Native (AI/AN) adults with dementia who access services through the Indian Health Service (IHS) and Tribal health programs.

METHODS

We analyzed fiscal year 2013 IHS/Tribal treatment costs for AI/ANs aged 65+ years with dementia and a matched sample without dementia (n = 1842) to report actual and adjusted total treatment costs and costs by service type. Adjusted costs were estimated using multivariable regressions.

RESULTS

Mean total treatment cost for adults with dementia were $13,027, $5400 higher than for adults without dementia ($7627). The difference in adjusted total treatment costs was $2943 (95% confidence interval [CI]: $1505, $4381), the majority of which was due to the difference in hospital inpatient costs ($2902; 95% CI: $1512, $4293).

DISCUSSION

Knowing treatment costs for AI/ANs with dementia can guide enhancements to policies and services for treating dementia and effectively using health resources.

How good are medical and death records for identifying dementia?

INTRODUCTION

Retrospective studies using administrative data may be an efficient way to assess risk factors for dementia if diagnostic accuracy is known.

METHODS

Within-individual clinical diagnoses of Alzheimer's disease (AD) and all-cause dementia in ambulatory (outpatient) surgery, inpatient, Medicare administrative records and death certificates were compared with research diagnoses among participants of Cache County Study on Memory, Health, and Aging (CCSMHA) (1995-2008, N = 5092).

RESULTS

Combining all sources of clinical health data increased sensitivity for identifying all-cause dementia (71%) and AD (48%), while maintaining relatively high specificity (81% and 93%, respectively). Medicare claims had the highest sensitivity for case identification (57% and 40%, respectively).

DISCUSSION

Administrative health data may provide a less accurate method than a research evaluation for identifying individuals with dementing disease, but accuracy is improved by combining health data sources. Assessing all-cause dementia versus a specific cause of dementia such as AD will result in increased sensitivity, but at a cost to specificity.

Associations between dementia diagnosis and end-of-life care utilization

BACKGROUND

Dementia is a leading cause of death for older adults and is more common among persons from racial/ethnic minoritized groups, who also tend to experience more intensive end-of-life care. This retrospective cohort study compared end-of-life care in persons with and without dementia and identified dementia's moderating effects on the relationship between race/ethnicity and end-of-life care.

METHODS

Administrative claims data for 463,590 Medicare fee-for-service decedents from 2016 to 2018 were analyzed. Multivariable logistic and linear regression analyses examined the association of dementia with 5 intensive and 2 quality of life-focused measures. Intensity measures included hospital admission, ICU admission, receipt of any of 5 intensive procedures (CPR, mechanical ventilation, intubation, dialysis initiation, and feeding tube insertion), hospital death, and Medicare expenditures (last 30 days of life). Quality of life measures included timely hospice care (>3 days before death) and days at home (last 6 months of life). Models were adjusted for demographic and clinical factors.

RESULTS

54% of Medicare decedents were female, 85% non-Hispanic White, 8% non-Hispanic Black, and 4% Hispanic. Overall, 51% had a dementia diagnosis claim. In adjusted models, decedents with dementia had 16%-29% lower odds of receiving intensive services (AOR hospital death: 0.71, 95% CI: 0.70-0.72; AOR hospital admission: 0.84, 95% CI: 0.83-0.86). Patients with dementia had 45% higher odds of receiving timely hospice (AOR: 1.45, 95% CI: 1.42-1.47), but spent 0.74 fewer days at home (adjusted mean: -0.74, 95% CI: (-0.98)-(-0.49)). Compared to non-Hispanic White individuals, persons from racial/ethnic minoritized groups were more likely to receive intensive services. This effect was more pronounced among persons with dementia.

CONCLUSIONS

Although overall dementia was associated with fewer intensive services near death, beneficiaries from racial/ethnic groups minoritized with dementia experienced more intensive service use. Particular attention is needed to ensure care aligns with the needs and preferences of persons with dementia and from racial/ethnic minoritized groups.

Risk of Alzheimer's disease and related dementia by sex and race/ethnicity: The Multiethnic Cohort Study

INTRODUCTION

Data are limited for comparison of sex- and race/ethnicity-specific risks of Alzheimer's disease and related dementia (ADRD).

METHODS

In the population-based Multiethnic Cohort, we estimated the age-standardized diagnostic incidence rate (ASDIR) and relative risk of late-onset ADRD (n = 16,410) among 105,796 participants based on Medicare claims (1999-2014) by sex and race/ethnicity.

RESULTS

The ASDIR for ADRD was higher for women (17.0 per 1000 person-years) than for men (15.3) and varied across African Americans (22.9 in women, 21.5 in men), Native Hawaiians (19.3, 19.4), Latinos (16.8, 14.7), Whites (16.4, 15.5), Japanese Americans (14.8, 13.8), and Filipinos (12.5, 9.7). Similar risk patterns were observed for AD. Adjustment for education and cardiometabolic diseases attenuated the differences. Accounting for deaths from competing causes increased the sex difference, while reducing the racial/ethnic differences. Less racial/ethnic disparity was detected among apolipoprotein E (APOE) e4 carriers.

DISCUSSION

More research is needed to understand the sex and racial/ethnic differences in ADRD.

Analyses and identification of ICD codes for dementias in the research based on the NHIRD: a scoping review protocol

INTRODUCTION

Studies based on health claims data (HCD) have been increasingly adopted in medical research for their strengths in large sample size and abundant information, and the Taiwan National Health Insurance Research Database (NHIRD) has been widely used in medical research across disciplines, including dementia. How the diagnostic codes are applied to define the diseases/conditions of interest is pivotal in HCD-related research, but the consensus on the issue that diagnostic codes most appropriately define dementias in the NHIRD is lacking. The objectives of this scoping review are (1) to investigate the relevant characteristics in the published reports targeting dementias based on the NHIRD, and (2) to address the diversity by a case study.

METHODS AND ANALYSIS

This scoping review protocol follows the methodological framework of the Joanna Briggs Institute Reviewer's Manual and the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. The review will be performed between 1 March and 31 December 2022 in five stages, including identifying the relevant studies, developing search strategies, individually screening and selecting evidence, collecting and extracting data, and summarising and reporting the results. The electronic databases of MEDLINE, EMBASE, CENTRAL, CINAHL, and PsycINFO, Airiti Library Academic Database, the National Health Insurance Administration's repository, and Taiwan Government Research Bulletin will be searched. We will perform narrative syntheses of the results to address research questions and will analyse the prevalence across the included individual studies as a case study.

ETHICS AND DISSEMINATION

Our scoping review is a review of the published reports and ethical approval is not required. The results will provide a panorama of the dementia studies based on the NHIRD. We will disseminate our findings through peer-reviewed journals and conferences, and share with stakeholders by distributing the summaries in social media and emails.

Dementia and Related Comorbidity: Analysis of 2 Years of Admissions to Italian Hospitals

BACKGROUND

The aim of the present study was to examine the prevalence of dementia, related comorbidities, and mortality rates in hospitalized elderly patients in Italy.

METHODS

Data were obtained from the Italian Ministry of Health and included all discharge records from Italian hospitals concerning subjects aged 65 years or above admitted to acute Internal Medicine during 2 years (n=3,695,278 admissions). Discharge diagnoses were re-classified into 24 clusters, each including homogeneous diseases by the ICD-9-CM code classification. Dementia was identified by the presence of ICD-9-CM codes 290, 294, or 331 series.

RESULTS

Patients with dementia represented 7.5% of the sample; compared with those without dementia, they were older and more often female, had a greater length of hospital stay and higher mortality rate. Besides delirium [odds ratio (OR): 54.20], enthesopaties (OR: 2.19), diseases of fluids and electrolytes (OR:1.96), diseases of arteries (OR: 1.69), skin diseases (OR: 1.64), and pneumonia and pleurisy (OR: 1.53) were the diseases more strongly associated with the diagnosis of dementia, independent of other clusters, age, sex, and length of stay.

CONCLUSIONS

Some comorbidities are specifically associated with the diagnosis of dementia among hospitalized elderly patients. Overall, these comorbidities describe the typical clinical profile of the patient with advanced dementia and could be treated in the context of the primary care, since they do not require specific skills belonging to hospital settings.

Evaluation of mild cognitive impairment and dementia in patients with metastatic renal cell carcinoma

BACKGROUND

Dementia and cancer are both more common in adults as they age. As new cancer treatments become more popular, it is important to consider how these treatments might affect older patients. This study evaluates metastatic renal cell carcinoma (mRCC) as a risk factor for older adults developing mild cognitive impairment or dementia (MCI/D) and the impact of mRCC-directed therapies on the development of MCI/D.

METHODS

We identified patients diagnosed with mRCC in a Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset from 2007 to 2015 and matched them to non-cancer controls. Exclusion criteria included age < 65 years at mRCC diagnosis and diagnosis of MCI/D within the year preceding mRCC diagnosis. The main outcome was time to incident MCI/D within one year of mRCC diagnosis for cases or cohort entry for non-cancer controls. Cox proportional hazards models were used to measure associations between mRCC and incident MCI/D as well as associations of oral anticancer agent (OAA) use with MCI/D development within the mRCC group.

RESULTS

Patients with mRCC (n = 2533) were matched to non-cancer controls (n = 7027). mRCC (hazard ratio [HR] 8.52, p < .001), being older (HR 1.05 per 1-year age increase, p < .001), and identifying as Black (HR 1.92, p = .047) were predictive of developing MCI/D. In addition, neither those initiating treatment with OAAs nor those who underwent nephrectomy were more likely to develop MCI/D.

CONCLUSIONS

Patients with mRCC were more likely to develop MCI/D than those without mRCC. The medical and surgical therapies evaluated were not associated with increased incidence of MCI/D. The increased incidence of MCI/D in older adults with mRCC may be the result of the pathology itself or risk factors common to the two disease processes.

Validation of Claims Algorithms to Identify Alzheimer's Disease and Related Dementias

BACKGROUND

Using billing data generated through health care delivery to identify individuals with dementia has become important in research. To inform tradeoffs between approaches, we tested the validity of different Medicare claims-based algorithms.

METHODS

We included 5 784 Medicare-enrolled, Health and Retirement Study participants aged older than 65 years in 2012 clinically assessed for cognitive status over multiple waves and determined performance characteristics of different claims-based algorithms.

RESULTS

Positive predictive value (PPV) of claims ranged from 53.8% to 70.3% and was highest using a revised algorithm and 1 year of observation. The tradeoff of greater PPV was lower sensitivity; sensitivity could be maximized using 3 years of observation. All algorithms had low sensitivity (31.3%-56.8%) and high specificity (92.3%-98.0%). Algorithm test performance varied by participant characteristics, including age and race.

CONCLUSION

Revised algorithms for dementia diagnosis using Medicare administrative data have reasonable accuracy for research purposes, but investigators should be cognizant of the tradeoffs in accuracy among the approaches they consider.

Cognitive impairment associated with greater care intensity during home health care

BACKGROUND

In Medicare-funded home health care (HHC), one in three patients has cognitive impairment (CI), but little is known about the care intensity they receive in this setting. Recent HHC reimbursement changes fail to adjust for patient CI, potentially creating a financial disincentive to caring for these individuals.

METHODS

This cohort study included a nationally representative sample of 1214 Medicare HHC patients between 2011 and 2016. Multivariable logistic and negative binomial regressions modelled the relationship between patient CI and care intensity-measured as the number and type of visits received during HHC and likelihood of receiving multiple successive HHC episodes.

RESULTS

Patients with CI had 45% (P < .05) greater odds of receiving multiple successive HHC episodes and received an additional 2.82 total (P < .001), 1.39 nursing (P = .003), 0.72 physical therapy (P = .03), and 0.60 occupational therapy visits (P = .01) during the index HHC episode.

DISCUSSION

Recent HHC reimbursement changes do not reflect the more intensive care needs of patients with CI.

Impact of Comorbid Dementia on Patterns of Hospice Use

Background: The evidence base for understanding hospice use among persons with dementia is almost exclusively based on individuals with a primary terminal diagnosis of dementia. Little is known about whether comorbid dementia influences hospice use patterns. Objective: To estimate the prevalence of comorbid dementia among hospice enrollees and its association with hospice use patterns. Design: Pooled cross-sectional analysis of the nationally representative Health and Retirement Study (HRS) linked to Medicare claims. Subjects: Fee-for-service Medicare beneficiaries in the United States who enrolled with hospice and died between 2004 and 2016. Measurements: Dementia was assessed using a validated survey-based algorithm. Hospice use patterns were enrollment less than or equal to three days, enrollment greater than six months, hospice disenrollment, and hospice disenrollment after six months. Results: Of 3123 decedents, 465 (14.9%) had a primary hospice diagnosis of dementia and 943 (30.2%) had comorbid dementia and died of another illness. In fully adjusted models, comorbid dementia was associated with increased odds of hospice enrollment greater than six months (adjusted odds ratio [AOR] = 1.52, 95% confidence interval [CI]: 1.11-2.09) and hospice disenrollment following six months of hospice (AOR = 2.55, 95% CI: 1.43-4.553). Having a primary diagnosis of dementia was associated with increased odds of hospice enrollment greater than six months (AOR = 2.62, 95% CI: 1.86-3.68), hospice disenrollment (AOR = 1.82, 95% CI: 1.32-2.51), and hospice disenrollment following six months of hospice (AOR = 4.31, 95% CI: 2.37-7.82). Conclusion: Approximately 45% of the hospice population has primary or comorbid dementia and are at increased risk for long hospice enrollment periods and hospice disenrollment. Consideration of the high prevalence of comorbid dementia should be inherent in hospice staff training, quality metrics, and Medicare Hospice Benefit policies.

Dementia diagnosis in the hospital and outcomes among patients with advanced dementia documented in the Minimum Data Set

BACKGROUND

Individuals with dementia do not always have a diagnosis of dementia noted on their hospital claims. Whether this lack of documentation is associated with patient outcomes is unknown. We examined the association between a dementia diagnosis listed on a hospital claim and patient outcomes among individuals with a Minimum Data Set (MDS) assessment.

METHODS

A retrospective cohort study was conducted using administrative claims data and nursing home MDS assessments. Hospitalized patients aged 66 and older with advanced dementia noted on an MDS assessment completed within 120 days prior to their first hospitalization in 2017 were included. Advanced dementia was defined based on an MDS diagnosis of dementia, dependency in four or more activities of daily living, and a Cognitive Function Scale score indicative of moderate to severe impairment. Multilevel regression with a random intercept at the hospital level was used to examine the relationship between documentation of dementia in inpatient hospital Medicare claims and the following patient outcomes after adjusting for patient and hospital characteristics: invasive mechanical ventilation (IMV) use, intensive care unit or coronary care unit (ICU/CCU) use, 30-day mortality, and hospital length of stay (LOS).

RESULTS

In 2017, among 120,989 patients with advanced dementia and a nursing home stay, 90.57% had a dementia diagnosis on their hospital claims. In adjusted models, documentation of a dementia diagnosis was associated with lower use of the ICU/CCU (adjusted odds ratio [AOR]: 0.78 [95% confidence interval 0.74, 0.81]), use of IMV (AOR: 0.50 [0.47, 0.54]), and 30-day mortality (AOR: 0.81 [0.77, 0.85]). Patients with a dementia diagnosis had a shorter LOS.

CONCLUSIONS

Among patients with advanced dementia, those whose dementia diagnosis was documented on their inpatient hospital Medicare claim experienced lower use of ICU/CCU, use of IMV, lower 30-day mortality, and shorter LOS than those whose diagnosis was not documented.

Medical and nursing home costs: From cognitively unimpaired through dementia

INTRODUCTION

Efforts to model the cost-effectiveness of managing/modifying cognitive impairment lack reliable, objective, baseline medical, and nursing-home (NH) costs.

METHODS

A stratified-random sample of Olmsted County, MN, residents ages 70-89 years (N = 3545), well-characterized as cognitively unimpaired, mild cognitive impairment (MCI), or dementia, were followed forward ≤1 year in provider-linked billing data and the Centers for Medicare & Medicaid Services NH assessments. Direct medical/nursing home/medical + NH costs were estimated. Costs were stratified by vital status and NH-use intensity (NH days/follow-up days [0%, 1% to 24%, 25% to 99%, and 100%]). Between-category mean-annual cost differences were adjusted for patient characteristics and follow-up days.

RESULTS

Costs/follow-up day distributions differed significantly across cognitive categories. Mean costs/follow-up days were 2.5 to 18 times higher for decedents versus survivors. Among all persons with MCI, <9% with any NH use accounted for 18% of all total annual medical + NH costs. Adjusted-between-category comparisons revealed significantly higher medical and medical + NH costs for MCI versus cognitively unimpaired.

DISCUSSION

Cost-effectiveness for managing/modifying both MCI and dementia should consider end-of-life costs and NH-use intensity. Results can help inform cost-effectiveness models, predict future-care needs, and aid decision-making by individuals/providers/payers/policymakers.

Skilled Nursing Facility-to-Home Trajectories for Older Adults With Mental Illness or Dementia

OBJECTIVES

To examine how mental illness (MI) and Alzheimer's disease and related dementias (ADRD) were associated with whether skilled nursing facility (SNF) residents returned to and remained in the community and if receipt of home health services was associated with post-SNF home time.

DESIGN

Retrospective cohort study based on secondary data analyses.

SETTING

New York State Medicare beneficiaries who were admitted to an SNF in 2014.

PARTICIPANTS

Total of 46,137 older adults admitted to SNFs and 25,357 discharged from SNFs to home.

MEASUREMENTS

We used Medicare claims and assessment databases to derive our outcomes (discharge to the community and home time [i.e., days alive in the community]), determine MI/ADRD status, and obtain socio-demographic and clinical characteristics.

RESULTS

Among SNF admissions, 22.9% had MI, 22.6% had ADRD, and 59.0% were discharged to the community. In analyses adjusting for socio-demographic and clinical characteristics, MI and ADRD were associated with decreased odds of community discharge and less home time during 90-days of follow-up. However, when we included depressive symptoms, aggressive behaviors, and daily functioning in the analyses, these associations were attenuated. Receipt of post-SNF home health services was associated with increased home time among those with MI or ADRD.

CONCLUSION

Newly admitted SNF residents with MI or ADRD were less likely to be discharged and, if discharged, spent less time in the community. Interventions targeting depressive symptoms, aggressive behaviors, and functioning and improving linkage with home health services may help decrease differences in post-acute care trajectories between those with and without MI and ADRD.

Estimation of dementia prevalence at the local level in the United States

INTRODUCTION

Ensuring adequate and equitable distribution of resources to support persons living with dementia relies on understanding the burden and distribution of dementia in a population. Our goal was to develop an approach to estimate dementia prevalence at the local level in the United States using publicly available data.

METHODS

Our approach combines publicly available data on dementia prevalence and demographic data from the US Census to estimate dementia prevalence. We illustrate this approach by estimating dementia prevalence in persons aged 65 and older in Philadelphia, PA; Chicago, IL; and Atlanta, GA.

RESULTS

Overall, we estimate the prevalence of dementia among those 65 and older to be 11.9% in Philadelphia, 11.8% Chicago, and 12.3% in Atlanta. Estimates across Philadelphia localities vary from 9.3% to 15.9%.

DISCUSSION

Our approach provides a cost-effective method to generate estimates of dementia prevalence at the local level.

HIGHLIGHTS

Brain health needs assessments require understanding of local dementia prevalence.Our approach can be used to estimate dementia prevalence in individual communities.This information can inform decisions about distribution of resources.

Cognitive impairment among medicare home health patients: comparing available measures

There is growing interest in understanding home health utilization and outcomes for those with cognitive impairment (CI). Yet, approaches to measuring CI during home health vary widely across studies, with little known regarding potential implications for findings. Among a nationally representative sample of community-living Medicare beneficiaries receiving home health (2011-2016), we compare estimated CI prevalence using four different measures and evaluate measure-specific strengths and limitations. CI prevalence estimates ranged from 18.4% of the sample with probable dementia from national survey data; to 27.8% with diagnosed dementia, from Medicare claims; to 26.7% with memory deficit and/or impaired decision-making and 43.9% with reduced cognitive function, from OASIS. Researchers must be deliberate in their choice of CI measure and transparent regarding its benefits and limitations. Regardless of the measure used, a sizable percentage of home health patients have CI, supporting the importance of ongoing research in this area.

What gets recorded, counts: dementia recording in primary care compared with a specialist database

BACKGROUND

databases of electronic health records are powerful tools for dementia research, but data can be influenced by incomplete recording. We examined whether people with dementia recorded in a specialist database (from a mental health and dementia care service) differ from those recorded in primary care.

METHODS

a retrospective cohort study of the population covered by Lambeth DataNet (primary care electronic records) between 2007 and 2019. Documentation of dementia diagnosis in primary care coded data and linked records in a specialist database (Clinical Records Interactive Search) were compared.

RESULTS

3,859 people had dementia documented in primary care codes and 4,266 in the specialist database, with 2,886/5,239 (55%) documented in both sources. Overall, 55% were labelled as having Alzheimer's dementia and 29% were prescribed dementia medication, but these proportions were significantly higher in those documented in both sources. The cohort identified from the specialist database were less likely to live in a care home (prevalence ratio 0.73, 95% confidence interval 0.63-0.85), have multimorbidity (0.87, 0.77-0.98) or consult frequently (0.91, 0.88-0.95) than those identified through primary care codes, although mortality did not differ (0.98, 0.91-1.06).

DISCUSSION

there is under-recording of dementia diagnoses in both primary care and specialist databases. This has implications for clinical care and for generalizability of research. Our results suggest that using a mental health database may under-represent those patients who have more frailty, reflecting differential referral to mental health services, and demonstrating how the patient pathways are an important consideration when undertaking database studies.

The prevalence and incidence of early-onset dementia among adults with autism spectrum disorder

The prevalence and incidence of early-onset dementia among adults with autism spectrum disorder (ASD) is currently unknown. In this case-control study, the prevalence and incidence of early-onset dementia in individuals with ASD was examined during 2008-2012 using Medicaid Analytic eXtract files. Participants were 30-64 year-old adults who were Medicaid beneficiaries and had either a diagnosis of ASD only (n = 12,648), a diagnosis of ASD with co-occurring intellectual disability (ID) (n = 26,168), a diagnosis of ID without ASD (n = 406,570), or no ASD nor ID diagnoses (n = 798,828). The 5-year prevalence of dementia was 4.04% among adults with ASD only, and 5.22% for those with ASD and co-occurring ID. This prevalence was higher compared to the prevalence of dementia in individuals with no ASD and no ID (0.97%), but lower compared to individuals with ID only (7.10%). Risk factors associated with the increased prevalence in the general population were similarly associated with the increased risk of dementia in individuals with ASD. Even after adjusting for these risk factors, compared to the general population, dementia was found to occur more frequently in individuals with ASD only (adjusted hazard ratio, 1.96; 95% CI, 1.69-2.28), as well as individuals with ASD and co-occurring ID (adjusted hazard ratio, 2.89; 95% CI, 2.62-3.17). In conclusion, adults with ASD under the age of 65 were approximately 2.6 times more likely to be diagnosed with dementia compared to the general population in our study. LAY SUMMARY: It is unclear whether adults diagnosed with autism spectrum disorder (ASD) are at higher risk of being diagnosed with early-onset dementia compared to those who are not on the autism spectrum. In this study we examined for the first time the nationwide prevalence and incidence of Alzheimer's Disease and other types of dementia in ASD in a sample of adults with ASD aged 30-64 years who were enrolled in Medicaid, the largest insurer of behavioral health services in the US. Medicaid claims data, which include information on the diagnoses that beneficiaries receive, suggested that the adults with ASD were approximately 2.6 times more likely to be diagnosed with early-onset Alzheimer's disease and related dementias compared to the general population.

Association of remote mild traumatic brain injury with cortical amyloid burden in clinically normal older adults

We investigated whether clinically normal older adults with remote, mild traumatic brain injury (mTBI) show evidence of higher cortical Aβ burden. Our study included 134 clinically normal older adults (age 74.1 ± 6.8 years, 59.7% female, 85.8% white) who underwent Aβ positron emission tomography (Aβ-PET) and who completed the Ohio State University Traumatic Brain Injury Identification questionnaire. We limited participants to those reporting injuries classified as mTBI. A subset (N = 30) underwent a second Aβ-PET scan (mean 2.7 years later). We examined the effect of remote mTBI on Aβ-PET burden, interactions between remote mTBI and age, sex, and APOE status, longitudinal Aβ accumulation, and the interaction between remote mTBI and Aβ burden on memory and executive functioning. Of 134 participants, 48 (36%) reported remote mTBI (0, N = 86; 1, N = 31, 2+, N = 17; mean 37 ± 23 years since last mTBI). Effect size estimates were small to negligible for the association of remote mTBI with Aβ burden (p = .94, η2 < 0.01), and for all interaction analyses. Longitudinally, we found a non-statistically significant association of those with remote mTBI (N = 11) having a faster rate of Aβ accumulation (B = 0.01, p = .08) than those without (N = 19). There was no significant interaction between remote mTBI and Aβ burden on cognition. In clinically normal older adults, history of mTBI is not associated with greater cortical Aβ burden and does not interact with Aβ burden to impact cognition. Longitudinal analyses suggest remote mTBI may be associated with more rapid cortical Aβ accumulation. This finding warrants further study in larger and more diverse samples with well-characterized lifelong head trauma exposure.

Continuity of Nursing Care in Home Health: Impact on Rehospitalization Among Older Adults With Dementia

BACKGROUND

Home health care (HHC) is a leading form of home and community-based services for persons with dementia (PWD). Nurses are the primary providers of HHC; however, little is known of nursing care delivery and quality.

OBJECTIVE

The objective of this study was to examine the association between continuity of nursing care in HHC and rehospitalization among PWD.

RESEARCH DESIGN

This is a retrospective cohort study using multiple years (2010-2015) of HHC assessment, administrative, and human resources data from a large urban not-for-profit home health agency.

SUBJECTS

This study included 23,886 PWD receiving HHC following a hospitalization.

MEASURES

Continuity of nursing care was calculated using the Bice and Boxerman method, which considered the number of total visits, nurses, and visits from each nurse during an HHC episode. The outcome was all-cause rehospitalization during HHC. Risk-adjusted logistic regression was used for analysis.

RESULTS

Approximately 24% of PWD were rehospitalized. The mean continuity of nursing care score was 0.56 (SD=0.33). Eight percent of PWD received each nursing visit from a different nurse (no continuity), and 26% received all visits from one nurse during an HHC episode (full continuity). Compared with those receiving high continuity of nursing care (third tertile), PWD receiving low (first tertile) or moderate (second tertile) continuity of nursing care had an adjusted odds ratio of 1.33 (95% confidence interval: 1.25-1.46) and 1.30 (95% confidence interval: 1.22-1.43), respectively, for being rehospitalized.

CONCLUSIONS

Wide variations exist in continuity of nursing care to PWD. Consistency in nurse staff when providing HHC visits to PWD is critical for preventing rehospitalizations.

Pain treatment and functional improvement in home health care: Relationship with dementia

BACKGROUND

Pain management is important to post-acute functional recovery, yet older persons with Alzheimer's disease and related dementias (ADRD) are often undertreated for pain. The main objectives were (1) to examine the relationship between ADRD and analgesic use among Medicare home health care (HHC) recipients with daily interfering pain, and (2) to examine the impact of analgesic use on functional outcome in patients with and without ADRD.

METHODS

We analyzed longitudinal data from the Outcome and Assessment Information Set, Medicare HHC claims, and HHC electronic medical records during a 60-day HHC episode. The sample included 6048 Medicare beneficiaries ≥65 years receiving care from an HHC agency in New York in 2019 who reported daily interfering pain. Analgesic use was assessed during HHC medication reconciliation and included any analgesic, non-opioid analgesic, and opioid. ADRD was identified from ICD-10 codes (HHC claims) and cognitive impairment symptoms (Outcome and Assessment Information Set [OASIS]). Functional outcome was measured as change in the composite Activity of Daily Living (ADL) limitation score in the HHC episode.

RESULTS

ADRD was related to a lower likelihood of using any analgesic (odds ratio [OR] = 0.66, 95% confidence interval [CI]: 0.49, 0.90, p = 0.008) and opioids (OR = 0.54, 95% CI: 0.47, 0.62, p < 0.001), but not related to non-opioid analgesic use (OR = 0.94, 95% CI: 0.74, 1.18, p = 0.58). Stratified analyses showed that any analgesic use (β = -0.43, 95% CI: -0.73, -0.13, p = 0.004) and non-opioid analgesic use (β = -0.31, 95% CI: -0.56, -0.06, p = 0.016) were associated with greater ADL improvement in patients with ADRD, but not in patients without ADRD. Opioid use was not significantly related to ADL improvement regardless of ADRD status.

CONCLUSIONS

HHC patients with ADRD may be undertreated for pain, yet pain treatment is essential for functional improvement in HHC. HHC clinicians and policymakers should ensure adequate pain management for older persons with ADRD for improved functional outcomes.

Dementia Diagnosis Disparities by Race and Ethnicity

BACKGROUND

Dementia is often underdiagnosed and this problem is more common among some ethnoracial groups.

OBJECTIVE

The objective of this study was to examine racial and ethnic disparities in the timeliness of receiving a clinical diagnosis of dementia.

RESEARCH DESIGN

This was a prospective cohort study.

SUBJECTS

A total of 3966 participants age 70 years and above with probable dementia in the Health and Retirement Study, linked with their Medicare and Medicaid claims.

MEASURES

We performed logistic regression to compare the likelihood of having a missed or delayed dementia diagnosis in claims by race/ethnicity. We analyzed dementia severity, measured by cognition and daily function, at the time of a dementia diagnosis documented in claims, and estimated average dementia diagnosis delay, by race/ethnicity.

RESULTS

A higher proportion of non-Hispanic Blacks and Hispanics had a missed/delayed clinical dementia diagnosis compared with non-Hispanic Whites (46% and 54% vs. 41%, P<0.001). Fully adjusted logistic regression results suggested more frequent missed/delayed dementia diagnoses among non-Hispanic Blacks (odds ratio=1.12; 95% confidence interval: 0.91-1.38) and Hispanics (odds ratio=1.58; 95% confidence interval: 1.20-2.07). Non-Hispanic Blacks and Hispanics had a poorer cognitive function and more functional limitations than non-Hispanic Whites around the time of receiving a claims-based dementia diagnosis. The estimated mean diagnosis delay was 34.6 months for non-Hispanic Blacks and 43.8 months for Hispanics, compared with 31.2 months for non-Hispanic Whites.

CONCLUSIONS

Non-Hispanic Blacks and Hispanics may experience a missed or delayed diagnosis of dementia more often and have longer diagnosis delays. When diagnosed, non-Hispanic Blacks and Hispanics may have more advanced dementia. Public health efforts should prioritize racial and ethnic underrepresented communities when promoting early diagnosis of dementia.

Resources, methods, and data infrastructure to promote research in dementia care, caregiving, and services

BACKGROUND

The National Institute on Aging, in conjunction with the Department of Health and Human Services as part of the National Alzheimer's Project Act, hosted a 2020 Dementia Care, Caregiving, and Services Research Summit Virtual Meeting Series on August 13, 2020. This article reflects three presentations related to Theme 6: Research Resources, Methods, and Data Infrastructure. Dr. Bynum discussed the challenges of identifying people for population- and healthcare-based research, including how definitions of dementia have changed over time, the opportunities and challenges inherent in the use of electronic data sources, and the need to fit data collection strategies to research goals and questions. Dr. Travison provided an overview on the growing use of embedded pragmatic clinical trials (ePCTs) and how to enhance their impact in dementia research. Dr. Wendler presented on the ethical considerations relevant to consent for dementia research, including assessment of decisional capacity and the role of decisional surrogates.

CONCLUSIONS

The availability of claims data, electronic health records, and other sources of "existing" data has made the use and development of ePCTs both easier and more appealing. Among other things, they offer advantages in terms of lower cost and generalizability to real-world settings. This is turn has necessitated the use of informatic and analytic approaches to account for some of the limitations and complexities of such data, including multilevel clustering and the need to link and jointly analyze data from the person with dementia and those of their care partner. As part of this process, it will be important to broaden the scope of who is assessed for decisional capacity, make those assessments more study specific, and assist surrogates in making decisions based on what the individual would have chosen for themselves if capacitated (i.e., substituted judgment).

Rural-urban differences in diagnostic incidence and prevalence of Alzheimer's disease and related dementias

INTRODUCTION

Understanding rural-urban variation in the diagnostic incidence and prevalence of Alzheimer's disease and related dementias (ADRD) will inform policies to improve timely diagnosis and access to supportive services for older adults in rural communities.

METHODS

Using 2008 to 2015 national claims data for fee-for-service Medicare beneficiaries (roughly 170 million person-years), we computed unadjusted and adjusted diagnostic incidence and prevalence estimates for ADRD in metropolitan, micropolitan, and rural counties, and examined differences in survival rates.

RESULTS

Risk-adjusted ADRD diagnostic incidence was higher in rural versus metropolitan counties despite lower prevalence. Among beneficiaries diagnosed with ADRD in 2008, metropolitan county residents experienced longer survival compared to residents in rural and micropolitan counties.

DISCUSSION

These data suggest that older adults in rural communities may be underdiagnosed with ADRD, and/or diagnosed at later stages of dementia. Further work is needed to develop strategies to reduce this disparity.

Development and Validation of a Model to Identify Alzheimer's Disease and Related Syndromes in Administrative Data

BACKGROUND

Administrative data are used in the field of Alzheimer's Disease and Related Syndromes (ADRS), however their performance to identify ADRS is unknown.

OBJECTIVE

i) To develop and validate a model to identify ADRS prevalent cases in French administrative data (SNDS), ii) to identify factors associated with false negatives.

METHODS

Retrospective cohort of subjects ≥ 65 years, living in South-Western France, who attended a memory clinic between April and December 2013. Gold standard for ADRS diagnosis was the memory clinic specialized diagnosis. Memory clinics' data were matched to administrative data (drug reimbursements, diagnoses during hospitalizations, registration with costly chronic conditions). Prediction models were developed for 1-year and 3-year periods of administrative data using multivariable logistic regression models. Overall model performance, discrimination, and calibration were estimated and corrected for optimism by resampling. Youden index was used to define ADRS positivity and to estimate sensitivity, specificity, positive predictive and negative probabilities. Factors associated with false negatives were identified using multivariable logistic regressions.

RESULTS

3360 subjects were studied, 52% diagnosed with ADRS by memory clinics. Prediction model based on age, all-cause hospitalization, registration with ADRS as a chronic condition, number of anti-dementia drugs, mention of ADRS during hospitalizations had good discriminative performance (c-statistic: 0.814, sensitivity: 76.0%, specificity: 74.2% for 2013 data). 419 false negatives (24.0%) were younger, had more often ADRS types other than Alzheimer's disease, moderate forms of ADRS, recent diagnosis, and suffered from other comorbidities than true positives.

CONCLUSION

Administrative data presented acceptable performance for detecting ADRS. External validation studies should be encouraged.

Clinical Features and Outcomes of Patients with Dementia Compared to an Aging Cohort Hospitalized During the Initial New York City COVID-19 Wave

Background:

Patients with dementia are vulnerable during the coronavirus disease 2019 (COVID-19) pandemic, yet few studies describe their hospital course and outcomes.

Objective:

To describe and compare the hospital course for COVID-19 patients with dementia to an aging cohort without dementia in a large New York City academic medical center.

Methods:

This was a single-center retrospective cohort study describing all consecutive patients age 65 or older with confirmed COVID-19 who presented to the emergency department or were hospitalized at New York-Presbyterian/Columbia University Irving Medical Center between March 6 and April 7, 2020.

Results:

A total of 531 patients were evaluated, including 116 (21.8%) with previously diagnosed dementia, and 415 without dementia. Patients with dementia had higher mortality (50.0%versus 35.4%, p = 0.006); despite similar comorbidities and complications, multivariate analysis indicated the association was dependent on age, sex, comorbidities, and code status. Patients with dementia more often presented with delirium (36.2%versus 11.6%, p < 0.001) but less often presented with multiple other COVID-19 symptoms, and these findings remained after adjusting for age and sex.

Conclusion:

Hospitalized COVID-19 patients with dementia had higher mortality, but dementia was not an independent risk factor for death. These patients were approximately 3 times more likely to present with delirium but less often manifested or communicated other common COVID-19 symptoms. For this high-risk population in a worsening pandemic, understanding the unique manifestations and course in dementia and aging populations may help guide earlier diagnosis and optimize medical management.

Changes in Health Care Use by Mexican American Medicare Beneficiaries Before and After a Diagnosis of Dementia

BACKGROUND

Evidence from predominantly non-Hispanic White cohorts indicates health care utilization increases before Alzheimer's disease and related dementias (ADRD) is diagnosed. We investigated trends in health care utilization by Mexican American Medicare beneficiaries before and after an incident diagnosis of ADRD.

METHODS

Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare claims files from 1999 to 2016 (n = 558 matched cases and controls). Piecewise regression and generalized linear mixed models were used to compare the quarterly trends in any (ie, one or more) hospitalizations, emergency room (ER) admissions, and physician visits for 1 year before and 1 year after ADRD diagnosis.

RESULTS

The piecewise regression models showed that the per-quarter odds for any hospitalizations (odds ratio [OR] = 1.62, 95% CI = 1.43-1.84) and any ER admissions (OR = 1.40, 95% CI = 1.27-1.54) increased before ADRD was diagnosed. Compared to participants without ADRD, the percentage of participants with ADRD who experienced any hospitalizations (27.2% vs 14.0%) and any ER admissions (19.0% vs 11.7%) was significantly higher at 1 quarter and 3 quarters before ADRD diagnosis, respectively. The per-quarter odds for any hospitalizations (OR = 0.88, 95% CI = 0.80-0.97) and any ER admissions (OR = 0.89, 95% CI = 0.82-0.97) decreased after ADRD was diagnosed. Trends for any physician visits before or after ADRD diagnosis were not statistically significant.

CONCLUSIONS

Older Mexican Americans show an increase in hospitalizations and ER admissions before ADRD is diagnosed, which is followed by a decrease after ADRD diagnosis. These findings support the importance of a timely diagnosis of ADRD for older Mexican Americans.

Dementia and Early Do-Not-Resuscitate Orders Associated With Less Intensive of End-of-Life Care: A Retrospective Cohort Study

BACKGROUND

Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital.

AIM

Examine the relationship between dementia, DNR timing, and end-of-life care intensity.

DESIGN

Observational cohort study.

SETTING/PARTICIPANTS

Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017.

RESULTS

Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission.

CONCLUSIONS

Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.

Demographic, Health, and Exposure Risks Associated With Cognitive Loss, Alzheimer's Disease and Other Dementias in US Military Veterans

The US military veteran population receiving care through the Veterans Health Administration (VHA) is particularly susceptible to cognitive impairment and dementias such as Alzheimer's disease and related dementias due to demographic, clinical, and economic factors. In this report we summarize the prevalence of dementia among US veterans and risks associated with AD and related dementias. We discuss the likelihood that these risks may be increasing in those about to enter the age in which dementias are common. We propose that VHA, the largest integrated health care system in the US, has shown promise in managing health risks that impact dementia prevention and propose further system wide approaches to be assessed for effective dementia prevention and care delivery.

Documentation of Dementia as a Cause of Death Among Mexican-American Decedents Diagnosed with Dementia

BACKGROUND

Hispanic older adults are a high-risk population for Alzheimer's disease and related dementias (ADRD) but are less likely than non-Hispanic White older adults to have ADRD documented as a cause of death on a death certificate.

OBJECTIVE

To investigate characteristics associated with ADRD as a cause of death among Mexican-American decedents diagnosed with ADRD.

METHODS

Data came from the Hispanic Established Populations for the Epidemiologic Study of the Elderly, Medicare claims, and National Death Index.

RESULTS

The final sample included 853 decedents diagnosed with ADRD of which 242 had ADRD documented as a cause of death. More health comorbidities (OR = 0.40, 95% CI = 0.28-0.58), older age at death (OR = 1.18, 95% CI = 1.03-1.36), and longer ADRD duration (OR = 1.08, 95% CI = 1.03-1.14) were associated with ADRD as a cause of death. In the last year of life, any ER admission without a hospitalization (OR = 0.45, 95% CI = 0.22-0.92), more physician visits (OR = 0.96, 95% CI = 0.93-0.98), and seeing a medical specialist (OR = 0.46, 95% CI = 0.29-0.75) were associated with lower odds for ADRD as a cause of death. In the last 30 days of life, any hospitalization with an ICU stay (OR = 0.55, 95% CI = 0.36-0.82) and ER admission with a hospitalization (OR = 0.67, 95% CI = 0.48-0.94) were associated with lower odds for ADRD as a cause of death. Receiving hospice care in the last 30 days of life was associated with 1.98 (95% CI = 1.37-2.87) higher odds for ADRD as a cause of death.

CONCLUSION

Under-documentation of ADRD as a cause of death may reflect an underestimation of resource needs for Mexican-Americans with ADRD.

Hospitalization and Socio-Health Care for Dementia in Spain

Dementias are brain diseases that affect long-term cognitive and behavioral functions and cause a decrease in the ability to think and remember that is severe enough to disturb daily functioning. In Spain, the number of people suffering from dementia is rising due to population ageing. Reducing admissions, many of them avoidable, would be advantageous for patients and care-providers. Understanding the correlation of admission of people with dementia and its trends in hospitalization would help us to understand the factors leading to admission. We conducted a cross-sectional study of the hospital discharge database of Castilla y León from 2005 to 2015, selecting hospitalizations for dementia. Trends in hospitalizations by year and age quartiles were studied by joinpoint regression analysis. 2807 out of 2,717,192 total hospitalizations (0.10%) were due to dementias; the main groups were degenerative dementia (1907) followed by vascular dementia (607). Dementias are not a major cause of hospitalization, but the average stay and cost are high, and many of them seem avoidable. Decreasing trends were detected in hospitalization rates for all dementias except for the group of mild cognitive impairment, which grew. An increasing–decreasing joinpoint detected in 2007 for vascular dementia and the general downward hospitalization trends for most dementias suggest that socio-health measures established since 2007 in Spain might play a key role in reducing hospitalizations.

Use of Patient-Reported Symptoms from an Online Symptom Tracking Tool for Dementia Severity Staging: Development and Validation of a Machine Learning Approach

BACKGROUND

SymptomGuide Dementia (DGI Clinical Inc) is a publicly available online symptom tracking tool to support caregivers of persons living with dementia. The value of such data are enhanced when the specific dementia stage is identified.

OBJECTIVE

We aimed to develop a supervised machine learning algorithm to classify dementia stages based on tracked symptoms.

METHODS

We employed clinical data from 717 people from 3 sources: (1) a memory clinic; (2) long-term care; and (3) an open-label trial of donepezil in vascular and mixed dementia (VASPECT). Symptoms were captured with SymptomGuide Dementia. A clinician classified participants into 4 groups using either the Functional Assessment Staging Test or the Global Deterioration Scale as mild cognitive impairment, mild dementia, moderate dementia, or severe dementia. Individualized symptom profiles from the pooled data were used to train machine learning models to predict dementia severity. Models trained with 6 different machine learning algorithms were compared using nested cross-validation to identify the best performing model. Model performance was assessed using measures of balanced accuracy, precision, recall, Cohen κ, area under the receiver operating characteristic curve (AUROC), and area under the precision-recall curve (AUPRC). The best performing algorithm was used to train a model optimized for balanced accuracy.

RESULTS

The study population was mostly female (424/717, 59.1%), older adults (mean 77.3 years, SD 10.6, range 40-100) with mild to moderate dementia (332/717, 46.3%). Age, duration of symptoms, 37 unique dementia symptoms, and 10 symptom-derived variables were used to distinguish dementia stages. A model trained with a support vector machine learning algorithm using a one-versus-rest approach showed the best performance. The correct dementia stage was identified with 83% balanced accuracy (Cohen κ=0.81, AUPRC 0.91, AUROC 0.96). The best performance was seen when classifying severe dementia (AUROC 0.99).

CONCLUSIONS

A supervised machine learning algorithm exhibited excellent performance in identifying dementia stages based on dementia symptoms reported in an online environment. This novel dementia staging algorithm can be used to describe dementia stage based on user-reported symptoms. This type of symptom recording offers real-world data that reflect important symptoms in people with dementia.

The direct health care cost to Medicare of Down syndrome dementia as compared with Alzheimer's disease among 2015 Californian beneficiaries

BACKGROUND

Aging individuals with Down syndrome (DS) are at increased risk of dementia due to trisomy of chromosome 21 on which the amyloid precursor protein gene is located and with increased life expectancy. Yet, little is known about the costs associated with DS dementia and how this compares to Alzheimer's disease (AD).

OBJECTIVE

To better understand direct healthcare costs and care consumption in DS dementia, we compared the total cost of care to US Medicare and the drivers of these medical expenditures in individuals with DS with and without dementia, and in those with AD without DS.

METHODS

The effect of dementia in DS on costs and care utilization was estimated with 2015 California Medicare fee-for-service data (parts A and B). Among 3,001,977 Californian Medicare beneficiaries, 353 individuals had DS with dementia (age 45-89 years). We compared their number of chronic comorbidity conditions among 27 and their care and Medicare costs to those of age- and sex-matched individuals with DS without dementia and those with AD without DS.

RESULTS

Medicare annual cost per beneficiary was a mean of 43.5% and 82.2% higher with DS dementia (mean $35,011) than DS without dementia (mean $24,401) and AD without dementia (mean $19,212), related to greater utilization of inpatient services. DS dementia was associated with increased level of multimorbidity (mean of 3.4 conditions in addition to dementia vs. 2.7 and 2.2 conditions for DS without dementia and AD, respectively), with more emergency room visits (88% vs. 76.5% and 54.4%) and with more primary care physician visits (91.2% vs. 87.3% and 81.3%).

CONCLUSION

DS adults with dementia have higher health care costs than DS adults without dementia and adults with AD. Understanding costs and complex health care needs in DS dementia could facilitate management of adult and geriatric care resources for these high-need high-cost individuals.

Using Medicare claims in identifying Alzheimer's disease and related dementias

INTRODUCTION

This study develops a measure of Alzheimer's disease and related dementias (ADRD) using Medicare claims.

METHODS

Validation resembles the approach of the American Psychological Association, including (1) content validity, (2) construct validity, and (3) predictive validity.

RESULTS

We found that four items-a Medicare claim recording ADRD 1 year ago, 2 years ago, 3 years ago, and a total stay of 6 months in a nursing home-exhibit a pattern of association consistent with a single underlying ADRD construct, and presence of any two of these four items predict a direct measure of cognitive function and also future claims for ADRD.

DISCUSSION

Our four items are internally consistent with the measurement of a single quantity. The presence of any two items do a better job than a single claim when predicting both a direct measure of cognitive function and future ADRD claims.

Medicaid Contributes Substantial Costs to Dementia Care in an Ethnically Diverse Community

OBJECTIVES

The main objective of this study was to estimate effects of dementia on Medicaid expenditures in an ethnically diverse community.

METHODS

The sample included 1,211 Medicare beneficiaries who did not have any Medicaid coverage and 568 who additionally had full Medicaid coverage enrolled in the Washington Heights-Inwood Columbia Aging Project (WHICAP), a multiethnic, population-based, prospective study of cognitive aging in northern Manhattan (1999-2010). Individuals' dementia status was determined using a rigorous clinical protocol. Relationship between dementia and Medicaid coverage and expenditures were estimated using a two-part model.

RESULTS

In participants who had full Medicaid coverage, average annual Medicaid expenditures were substantially higher for those with dementia than those without dementia ($50,270 vs. $21,966, p < .001), but Medicare expenditures did not differ by dementia status ($8,458 vs. $9,324, p = .19). In participants who did not have any Medicaid coverage, average annual Medicare expenditures were substantially higher for those with dementia than those without dementia ($12,408 vs. $8,113, p = .02). In adjusted models, dementia was associated with a $6,278 increase in annual Medicaid spending per person after controlling for other characteristics.

DISCUSSION

Results highlight Medicaid's contribution to covering the cost of dementia care in addition to Medicare. Studies that do not include Medicaid are unlikely to accurately reflect the true cost of dementia.

Functional outcome in home health: Do racial and ethnic minority patients with dementia fare worse?

Objectives

Evaluate the independent and interactive effects of dementia and racial/ethnic minority status on functional outcomes during a home health (HH) admission among Medicare beneficiaries.

Methods

Secondary analysis of data from the Outcome and Assessment Information Set [OASIS] and billing records in a non-profit HH agency in New York. Participants were adults ≥ 65 years old who received HH in CY 2017 with OASIS records at HH admission and HH discharge. Dementia was identified by diagnosis (ICD-10 codes) and cognitive impairment (OASIS: M1700, M1710, M1740). We used OASIS records to assess race/ethnicity (M0140) and functional status (M1800-M1870 on activities of daily living [ADL]). Functional outcome was measured as change in the composite ADL score from HH admission to HH discharge, where a negative score means improvement and a positive score means decline.

Results

The sample included 4,783 patients, among whom 93.9% improved in ADLs at HH discharge. In multivariable linear regression that adjusted for HH service use and covariates (R² = 0.23), being African American (β = 0.21, 95% confidence interval [CI]: 0.06, 0.35, p = 0.005) and having dementia (β = 0.51, 95% CI: 0.41, 0.62, p<0.001) were independently related to less ADL improvement at HH discharge, with significant interaction related to further decrease in ADL improvement. Relative to white patients without dementia, African American patients with dementia (β = 1.08, 95% CI: 0.81, 1.35, p<0.001), Hispanics with dementia (β = 0.92, 95% CI: 0.38, 1.47, p = 0.001) and Asian Americans with dementia (β = 1.47, 95% CI: 0.81, 2.13, p<0.001) showed the least ADL improvement at HH discharge.

Conclusion

Racial/ethnic minority status and dementia were associated with less ADL improvement in HH with independent and interactive effects. Policies should ensure that these patients have equitable access to appropriate, adequate community-based services to meet their needs in ADLs and disease management for improved outcomes.

Healthcare utilization of Mexican-American Medicare beneficiaries with and without Alzheimer's disease and related dementias

Background

Older adults with Alzheimer’s disease and related dementias (ADRD) are high-risk to experience hospitalizations and emergency room (ER) admissions. Mexican-Americans have a high prevalence of ADRD, but there is limited information on the healthcare use of older Mexican-Americans with ADRD. We used data from a cohort of older Mexican-Americans that has been linked with Medicare files to investigate differences in hospitalizations, ER admissions, and physician visits according to ADRD diagnosis. We also identify sociodemographic, health, and functional characteristics that may contribute to differences in healthcare utilization between Mexican-American Medicare beneficiaries with and without an ADRD diagnosis.

Methods and findings

Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare Master Beneficiary Summary Files, Medicare Provider Analysis and Review files, Outpatient Standard Analytic files, and Carrier files. The final analytic sample included 1048 participants. Participants were followed for two years (eight quarters) after their survey interview. Generalized estimating equations were used to estimate the probability for one or more hospitalizations, ER admissions, and physician visits at each quarter. ADRD was associated with higher odds for hospitalizations (OR = 1.65, 95%CI = 1.29–2.11) and ER admissions (OR = 1.57, 95%CI = 1.23–1.94) but not physician visits (OR = 1.23, 95%CI = 0.91–1.67). The odds for hospitalizations (OR = 1.24, 95%CI = 0.97–1.60) and ER admissions (OR = 1.27, 95%CI = 1.01–1.59) were reduced after controlling for limitations in activities of daily living and comorbidities.

Conclusions

Mexican-American Medicare beneficiaries with ADRD had significantly higher odds for one or more hospitalizations and ER admissions but similar physician visits compared to beneficiaries without ADRD. Functional limitations and comorbidities contributed to the higher hospitalizations and ER admissions for older Mexican-Americans with ADRD.

Validation of Random Forest Machine Learning Models to Predict Dementia-Related Neuropsychiatric Symptoms in Real-World Data

BACKGROUND

Neuropsychiatric symptoms (NPS) are the leading cause of the social burden of dementia but their role is underestimated.

OBJECTIVE

The objective of the study was to validate predictive models to separately identify psychotic and depressive symptoms in patients diagnosed with dementia using clinical databases representing the whole population to inform decision-makers.

METHODS

First, we searched the electronic health records of 4,003 patients with dementia to identify NPS. Second, machine learning (random forest) algorithms were applied to build separate predictive models for psychotic and depressive symptom clusters in the training set (N = 3,003). Third, calibration and discrimination were assessed in the test set (N = 1,000) to assess the performance of the models.

RESULTS

Neuropsychiatric symptoms were noted in the electronic health record of 58% of patients. The area under the receiver operating curve reached 0.80 for the psychotic cluster model and 0.74 for the depressive cluster model. The Kappa index and accuracy also showed better discrimination in the psychotic model. Calibration plots indicated that both types of model had less predictive accuracy when the probability of neuropsychiatric symptoms was <25%. The most important variables in the psychotic cluster model were use of risperidone, level of sedation, use of quetiapine and haloperidol and the number of antipsychotics prescribed. In the depressive cluster model, the most important variables were number of antidepressants prescribed, escitalopram use, level of sedation, and age.

CONCLUSION

Given their relatively good performance, the predictive models can be used to estimate prevalence of NPS in population databases.

Association Between Home Health Services and Facility Admission in Older Adults With and Without Alzheimer's Disease

OBJECTIVES

To evaluate the association between home health (HH) services, including skilled nursing (SN), physical therapy (PT), occupational therapy, social work (SW), and homemaking aide assistance with the hazard of unplanned facility admissions among Medicare patients with and without Alzheimer's disease and related dementias (ADRD).

DESIGN

Analysis of the Outcome and Assessment Information Set and billing records.

SETTING

A not-for-profit HH agency serving multiple counties in New York State.

PARTICIPANTS

Adults ≥65 years old who received HH from January 1, 2017 to December 31, 2017.

MEASURES

Outcome was time from HH start of care to an unplanned facility admission of any type, including the hospital, nursing home, and rehabilitation facility. Independent variables included weekly intensity (visits/week, hours/week) of SN, PT, occupational therapy, SW, and, homemaking aide assistance separately. ADRD was identified by diagnosis (International Classification of Diseases, Tenth Revision codes in billing records) and cognitive impairment assessment (Outcome and Assessment Information Set).

RESULTS

Of the sample (N = 6153), 14.9% had an unplanned facility admission. In multivariable Cox proportional hazard models that adjusted for time-varying effects of HH intensity and covariates, receiving the highest intensity of SN (3.3 visits of 2.78 hours per week) and PT (2.5 visits of 2 hours per week) was related to up to a 54% and 86% decrease, respectively, in the hazard of unplanned facility admission among patients with ADRD (n = 1525), and decreases of 56% and 90%, respectively, among patients without ADRD (n = 4628). Receiving any SW was related to 40% decreased in the hazard of facility admission in patients without ADRD only. Other HH services were not consistently related to the risk of facility admission.

CONCLUSIONS AND IMPLICATIONS

Receiving a higher intensity of SN and PT was associated with reduced hazards of unplanned facility admission among HH patients with and without ADRD. Policies should ensure that patients with ADRD receive a sufficient amount and appropriate mix of HH services.