The cost of dementia in Denmark: the Odense Study

The Costs of Dementia in Europe: An Updated Review and Meta-analysis

BACKGROUND AND OBJECTIVE

The prevalence of dementia is increasing, while new opportunities for diagnosing, treating and possibly preventing Alzheimer's disease and other dementia disorders are placing focus on the need for accurate estimates of costs in dementia. Considerable methodological heterogeneity creates challenges for synthesising the existing literature. This study aimed to estimate the costs for persons with dementia in Europe, disaggregated into cost components and informative patient subgroups.

METHODS

We conducted an updated literature review searching PubMed, Embase and Web of Science for studies published from 2008 to July 2021 reporting empirically based cost estimates for persons with dementia in European countries. We excluded highly selective or otherwise biased reports, and used a random-effects meta-analysis to produce estimates of mean costs of care across five European regions.

RESULTS

Based on 113 studies from 17 European countries, the estimated mean costs for all patients by region were highest in the British Isles (73,712 EUR), followed by the Nordics (43,767 EUR), Southern (35,866 EUR), Western (38,249 EUR), and Eastern Europe and Baltics (7938 EUR). Costs increased with disease severity, and the distribution of costs over informal and formal care followed a North-South gradient with Southern Europe being most reliant on informal care.

CONCLUSIONS

To our knowledge, this study represents the most extensive meta-analysis of the cost for persons with dementia in Europe to date. Though there is considerable heterogeneity across studies, much of this is explained by identifiable factors. Further standardisation of methodology for capturing resource utilisation data may further improve comparability of future studies. The cost estimates presented here may be of value for cost-of-illness studies and economic evaluations of novel diagnostic technologies and therapies for Alzheimer's disease.

Long-term medical costs of Alzheimer's disease: matched cohort analysis

OBJECTIVES

Medical costs associated with Alzheimer's disease (AD) are characterised by uncertainty and are often presented in a format unsuitable for decision modelling. We set out to estimate long-term medical costs attributable to AD compared to the general population for use in decision modelling.

METHODS

We used multiple logistic regressions to generate propensity scores to match 26,951 incident cases of AD with 26,951 people without AD, identified from Danish hospital and medication registries. Costs were available for up to 11 years for each individual, representing costs for 10 years before and 5 years after diagnosis. Generalised estimating equations were employed to investigate the effect of having AD on primary care, medication, hospital and total costs in the matched cohort. We also explored the impact of other socio-economic and demographic factors on healthcare costs.

RESULTS

We report costs by year to diagnosis, from 10 years before to 5 after. AD was associated with significantly higher costs, driven by medication and hospital costs, especially around the time of diagnosis. Mean total medical cost was €4996 higher for AD than for the control group in year of diagnosis, after which primary and hospital costs decreased to pre-diagnostic levels. AD had higher attributable primary care costs in years preceding diagnosis.

CONCLUSIONS

Reporting AD-attributable costs by year to diagnosis can be useful for use in decision modelling. Medical costs attributed to AD are driven by diagnostic procedures and medication, and the impact of AD on medical costs may not be as high or prolonged as previously suggested.

Health care utilisation among older persons with intellectual disability and dementia: a registry study

BACKGROUND

Both persons with intellectual disability (ID) and persons with dementia have high disease burdens, and consequently also high health care needs. As life expectancy increases for persons with ID, the group of persons with the dual diagnosis of ID and dementia will become larger.

METHOD

Through national registries, we identified 7936 persons who had received support directed to persons with ID during 2012, and an age- and gender-matched sample from the general population. A national registry was also used to collect information on health care utilisation (excluding primary care) for the period 2002-2012. Health care utilisation was measured as presence and number of planned and unplanned in-patient and out-patient visits, as well as length of stay.

RESULTS

In comparison with persons with ID but without dementia, persons with ID and dementia were more likely to have at least one planned out-patient visit (odds ratio [OR] 8.07), unplanned out-patient visit (OR 2.41), planned in-patient visit (OR 2.76) or unplanned in-patient visit (OR 4.19). However, among those with at least one of each respective outcome, the average number of visits did not differ between those with and without dementia. Persons with ID and dementia were less likely to have at least one planned out-patient visit than persons with dementia in the general population sample (OR 0.40), but more likely to have at least one unplanned in-patient visit (OR 1.90). No statistically significant differences were found for having at least one unplanned out-patient or planned in-patient visit. Nevertheless, among those with at least one unplanned out-patient visit, the number of visits was higher in the general population sample.

CONCLUSIONS

Persons with ID and dementia are less likely to receive planned health care than persons with dementia in the general population. They have, however, higher levels of unplanned health care utilisation. This may be an indication that the current support system is not sufficient to meet the challenges of increased longevity among persons with ID.

Effects of Diagnosed Dementia on Medicare and Medicaid Program Costs

This study examines the impacts of physician-diagnosed Alzheimer's disease and related dementias (ADRD) on Medicare and Medicaid program costs in 1994 and 1999. An innovative method is employed to estimate program payments over the life cycle starting at age 65. Using data from the 1994 and 1999 National Long-Term Care Surveys, merged Medicare claims, and national program data for Medicaid, we find that the share of total Medicare and Medicaid payments attributable to diagnosed ADRD was 5.46% in 1999. Total annual program payments attributable to ADRD decreased between 1994 and 1999, in contrast to an increase implied by a cross-sectional approach.

Using Propensity Score Matching Technique to Estimate Utilization and Costs of General Practitioners' Services associated with Alzheimer's Disease

Objective: General practitioners (GPs) play an important role in caring for people with Alzheimer's disease (AD). However, the cost and the extent of service utilization from GPs due to AD patients are difficult to assess. This study aimed to explore the principles of propensity score matching (PSM) technique to assess the additional GP service use and cost imposed by AD in persons aged ≥60 years in Denmark. Design: PSM was used to estimate the additional use and cost of GP services attributable to AD. Case and control baseline characteristics were compared with and without the application of PSM. Propensity scores were then estimated using the generalized boosted model, a multivariate, nonparametric and automated algorithm technique. Setting: Observational data from Statistics Denmark registry.

SUBJECTS

3368 cases and 3368 controls; cases with AD were defined as patients with diagnoses G30 and F00 and/or those with primary care prescriptions for anti-AD drugs from the years 2004 until 2009.

MAIN OUTCOME MEASURES

GP service utilisation and costs attributable to AD.

RESULTS

PSM brought a large improvement to the balance of observed covariates among the cases and control groups. AD patients received around 20% more GP services and utilized services that cost 15% more than non-AD controls during a calendar year.

CONCLUSION

AD patients utilize more GP services and incur higher costs as compared to their matched controls. The PSM technique can be an effective tool to reduce imbalance of observable confounders from register based data and improve the estimations.

Relationship between global severity of patients with Alzheimer's disease and costs of care in Spain; results from the co-dependence study in Spain

OBJECTIVE

The objectives of this analysis were to examine how patients' global severity with Alzheimer's disease (AD) relates to costs of care and explore the incremental effects of global severity measured by the clinical dementia rating (CDR) scale on these costs for patients in Spain.

METHODS

The Codep-EA study is an 18-multicenter, cross-sectional, observational study among patients (343) with AD according to the CDR score and their caregivers in Spain. The data obtained included (in addition to clinical measures) also socio-demographic data concerning the patient and its caregiver. Cost analyses were based on resource use for medical care, social care, caregiver productivity losses, and informal caregiver time reported in the resource utilization in dementia (RUD). Lite instrument and a complementary questionnaire. Multivariate regression analysis was used to model the effects of global severity and other socio-demographic and clinical variables on cost of care.

RESULTS

The mean (standard deviation) costs per patient over 6 months for direct medical, social care, indirect and informal care costs, were estimated at €1,028.1 (1,655.0), €843.8 (2,684.8), €464.2 (1,639.0) and €33,232.2 (30,898.9), respectively. Dementia severity, as having a CDR score 0.5, 2, or 3 with CDR score 1 being the reference group were all independently and significantly associated with informal care costs. Whereas having a CDR score of 2 was also significantly related with social care costs, a CDR score of 3 was associated with most cost components including direct medical, social care, and total costs, all compared to the reference group.

CONCLUSIONS

The costs of care for patients with AD in Spain are substantial, with informal care accounting for the greatest part. Dementia severity, measured by CDR score, showed that with increasing severity of the disease, direct medical, social care, informal care and total costs augmented.

Health care resource utilisation in primary care prior to and after a diagnosis of Alzheimer's disease: a retrospective, matched case-control study in the United Kingdom

BACKGROUND

This study examined medical resource utilisation patterns in the United Kingdom (UK) prior to and following Alzheimer's disease (AD) diagnosis.

METHODS

A patient cohort aged 65 years and older with newly diagnosed AD between January 2008 and December 2010 was identified through the UK's Clinical Practice Research Datalink (CPRD). Patients with a continuous record in the CPRD (formerly the General Practice Research Database [GPRD]) for both the 3 years prior to, and the 1 year following, AD diagnosis were eligible for inclusion. A control cohort was identified by matching general older adult (GOA) patients to patients with AD based on year of birth, gender, region, and Charlson Comorbidity Index at a ratio of 2:1. Medical resource utilisation was calculated in 6-month intervals over the 4-year study period. Comparisons between AD and GOA control cohorts were conducted using conditional logistic regression for patient characteristics and a generalised linear model for resource utilisation.

RESULTS

Data for the AD cohort (N = 3,896) and matched GOA control cohort (N = 7,792) were extracted from the CPRD. The groups were 65% female and the AD cohort had a mean age of 79.9 years (standard deviation 6.5 years) at the date of diagnosis. Over the entire study period, the AD cohort had a significantly higher mean primary care consultation rate than the GOA cohort (p < .0001). While the GOA cohort primary care consultation rate gradually increased over the 4-year period (ranging from 5 to 7 consultations per 6-month period), increases were more pronounced in the AD cohort (ranging from 6 to 11 consultations per 6-month period, peaking during the 6-month periods immediately prior to and post diagnosis). The AD cohort also had a higher overall specialty referral rate than the GOA cohort over the 4-year period (37% vs. 25%, respectively; p < .0001); the largest difference was during the 6 months immediately prior to AD diagnosis (17% vs. 5%, respectively; p < .0001).

CONCLUSIONS

In the UK, AD diagnosis is associated with significant increases in primary and secondary care resource utilisation, continuing beyond diagnosis. This evidence may be important to health care commissioners to facilitate effective mobilisation of appropriate AD-related health care resources.

The worldwide economic impact of dementia 2010

OBJECTIVE

To acquire an understanding of the societal costs of dementia and how they affect families, health and social care services, and governments to improve the lives of people with dementia and their caregivers.

METHODS

The basic design of this study was a societal, prevalence-based, gross cost-of-illness study in which costs were aggregated to World Health Organization regions and World Bank income groupings.

RESULTS

The total estimated worldwide costs of dementia were US$604 billion in 2010. About 70% of the costs occurred in western Europe and North America. In such high-income regions, costs of informal care and the direct costs of social care contribute similar proportions of total costs, whereas the direct medical costs were much lower. In low- and middle-income countries, informal care accounts for the majority of total costs; direct social care costs are negligible.

CONCLUSIONS

Worldwide costs of dementia are enormous and distributed inequitably. There is considerable potential for cost increases in coming years as the diagnosis and treatment gap is reduced. There is also likely to be a trend in low- and middle-income countries for social care costs to shift from the informal to the formal sector, with important implications for future aggregated costs and the financing of long-term care. Only by investing now in research and the development of cost-effective approaches to early diagnosis and care can future societal costs be anticipated and managed.

Dementia and out-of-pocket spending on health care services

BACKGROUND

High levels of out-of-pocket (OOP) spending for health care may lead patients to forego needed services and medications as well as hamper their ability to pay for other essential goods. Because it leads to disability and the loss of independence, dementia may put patients and their families at risk for high OOP spending, especially for long-term care services.

METHODS

We used data from the Aging, Demographics, and Memory Study, a nationally representative subsample (n = 743) of the Health and Retirement Study, to determine whether individuals with dementia had higher self-reported OOP spending compared with those with cognitive impairment without dementia and those with normal cognitive function. We also examined the relationship between dementia and utilization of dental care and prescription medications-two types of health care that are frequently paid for OOP. Multivariate and logistic regression models were used to adjust for the influence of potential confounders.

RESULTS

After controlling for demographics and comorbidities, those with dementia had more than three times the yearly OOP spending compared with those with normal cognition ($8216 for those with dementia vs. $2570 for those with normal cognition, P < .01). Higher OOP spending for those with dementia was mainly driven by greater expenditures on nursing home care (P < .01). Dementia was not associated with the likelihood of visiting the dentist (P = .76) or foregoing prescription medications owing to cost (P = .34).

CONCLUSIONS

Dementia is associated with high levels of OOP spending but not with the use of dental care or foregoing prescription medications, suggesting that excess OOP spending among those with dementia does not "crowd out" spending on these other health care services.

Systematic review of economic evaluations of Alzheimer's disease medications

This systematic review was conducted to summarize published pharmacoeconomic studies of Alzheimer's disease (AD) medications. Pharmacoeconomic studies were included in the review if they were published in English and contained a full and complete report of an original economic evaluation. The studies also had to be comparative in nature (i.e., cost-benefit, cost-effectiveness, cost-utility or cost-minimization analyses). Existing AD medications were found to dominate standard treatment (i.e., no drugs), or they were found to be more costly and more effective than standard treatment. Estimates of cost and effect varied widely because of different underlying models, assumptions and data sources. More research is needed to draw firmer conclusions regarding the overall cost-effectiveness of AD medications.

Methodological considerations in cost of illness studies on Alzheimer disease

Cost-of-illness studies (COI) can identify and measure all the costs of a particular disease, including the direct, indirect and intangible dimensions. They are intended to provide estimates about the economic impact of costly disease. Alzheimer disease (AD) is a relevant example to review cost of illness studies because of its costliness.The aim of this study was to review relevant published cost studies of AD to analyze the method used and to identify which dimension had to be improved from a methodological perspective. First, we described the key points of cost study methodology. Secondly, cost studies relating to AD were systematically reviewed, focussing on an analysis of the different methods used. The methodological choices of the studies were analysed using an analytical grid which contains the main methodological items of COI studies. Seventeen articles were retained. Depending on the studies, annual total costs per patient vary from $2,935 to $52, 954. The methods, data sources, and estimated cost categories in each study varied widely. The review showed that cost studies adopted different approaches to estimate costs of AD, reflecting a lack of consensus on the methodology of cost studies. To increase its credibility, closer agreement among researchers on the methodological principles of cost studies would be desirable.

Excess costs of dementia disorders and the role of age and gender - an analysis of German health and long-term care insurance claims data

BACKGROUND

Demographic ageing is associated with an increasing number of dementia patients, who reportedly incur higher costs of care than individuals without dementia. Regarding Germany, evidence on these excess costs is scarce. Adopting a payer perspective, our study aimed to quantify the additional yearly expenditures per dementia patient for various health and long-term care services. Additionally, we sought to identify gender-specific cost patterns and to describe age-dependent cost profiles.

METHODS

The analyses used 2006 claims data from the AOK Bavaria Statutory Health Insurance fund of 9,147 dementia patients and 29,741 age- and gender-matched control subjects. Cost predictions based on two-part regression models adjusted for age and gender and excess costs of dementia care refer to the difference in model-estimated means between both groups. Corresponding analyses were performed stratified for gender. Finally, a potentially non-linear association between age and costs was investigated within a generalized additive model.

RESULTS

Yearly spending within the social security system was circa €12,300 per dementia patient and circa €4,000 per non-demented control subject. About two-thirds of the additional expenditure for dementia patients occurred in the long-term care sector. Within our study sample, male and female dementia patients incurred comparable total costs. However, women accounted for significantly lower health and significantly higher long-term care expenditures. Long-term care spending increased in older age, whereupon health care spending decreased. Thus, at more advanced ages, women incurred greater costs than men of the same age.

CONCLUSIONS

Dementia poses a substantial additional burden to the German social security system, with the long-term care sector being more seriously challenged than the health care sector. Our results suggest that female dementia patients need to be seen as a key target group for health services research in an ageing society. It seems clear that strategies enabling community-based care for this vulnerable population might contribute to lowering the financial burden caused by dementia. This would allow for the sustaining of comprehensive dementia care within the social security system.

Costs of informal care for people suffering from dementia: evidence from a danish survey

BACKGROUND/AIMS

Around 70,000-80,000 Danes suffer from dementia. As average life expectancy increases, the number of people suffering from dementia is expected to increase in the future with informal care provided by family and friends becoming more important. The aim of this study was to estimate the time spent by family and friends on informal care of persons suffering from dementia in a Danish setting and calculate the economic implications.

METHODS

Information on informal care time was collected in a postal survey of members of the Danish Alzheimer's Association. Data from 469 informal caregivers were obtained corresponding to an adjusted response rate of 62%.

RESULTS

On a typical day, informal care time was 4.97-6.91 h for primary caregivers and 0.70-1.06 h for other caregivers. Using the proxy good method to value informal care, daily costs ranged between EUR 160 and 223 for primary caregivers and between EUR 23 and 34 for others.

CONCLUSION

Informal care delivered by family and friends is significant. The value of informal care constitutes an important part of the societal cost of dementia in Denmark.

Systematic review on the efficacy and safety of herbal medicines for vascular dementia

We present a systematic review of existing research that aims to assess the efficacy and safety of herbal medications (HM), as either monotherapy or adjunct to orthodox medications (OM), mainly comprised of cholinesterase inhibitors, for vascular dementia (VaD). We included 47 studies conducted in mainland China, each testing different HM. Of 43 HM monotherapy studies, 37 reported HM to be significantly better than OM or placebo; six reported similar efficacy between HM and OM. All four HM adjuvant studies reported significant efficacy. No major adverse events for HM were reported. Heterogeneity in diagnostic criteria, interventions and outcome measures hindered comprehensive data analysis. Studies suggested that HM can be a safe and effective treatment for VaD, either alone or in conjunction with OM. However, methodological flaws in the design of the studies limited the extent to which the results could be interpreted. Thirty most commonly used herbal constituents, including Rhizoma Chuanxiong (Chuanxiong in Chinese), Radix Polygoni Multiflori (Heshouwu in Chinese) and Radix Astragali (Huangqi in Chinese). were ranked. Further multi-center trials with large sample sizes, high methodological quality and standardized HM ingredients are necessary for clinical recommendations to be made.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Costs of care for dementia patients in community setting: an analysis for mild and moderate disease stage

OBJECTIVE

Rising life expectancy is associated with higher prevalence rates of dementia disorders. When disease progresses the patients' call on formal health care services and on social support grows which imposes increasing costs of care. The aim of this study was to investigate the costs for patients with mild and moderate dementia in community setting in Germany.

METHODS

We assessed total costs of care and individual cost components for 383 community-living dementia patients alongside a cluster-randomized trial from societal and health insurance perspective. Utilization of formal health care services was based on insurance claims data and time dedicated to informal care was assessed within caregiver interviews. We estimated costs using a two-part regression model adjusting for age, gender and cluster-effects.

RESULTS

Costs of care equal €47,747 (Euros) from societal perspective which is almost the 4.7-fold of health insurance expenditures. Valued informal care covers 80.2% of societal costs and increases disproportionally when disease progresses. In moderate dementia the corresponding amount exceeds the one in mild dementia by 69.9%, whereas costs for formal health care services differ by 14.3%.

CONCLUSION

Due to valued informal care, costs of care for community-living patients with moderate dementia are significantly higher than for patients with mild dementia. Informal care is a non-cash item saving expenditures for professional care. To relieve social security system and family caregivers as well as to allow dementia patients to stay at home as long as possible, concepts fostering community-based dementia care and support to family caregivers need to be further developed.

The economic impact of dementia in Europe in 2008-cost estimates from the Eurocode project

OBJECTIVE

Care for demented people is very resource demanding, the prevalence is increasing and there is so far no cure. Cost of illness (CoI) studies are important by identifying the distribution of costs between different payers of care. The European Union (EU) funded the European Collaboration on Dementia (Eurocode) as part of the EU's 2005 work plan of the Community public health programme. Eurocode was administered by Alzheimer Europe. The aim was to describe the economic impact of dementia in Europe in 2008.

METHODS

Eurocode's new estimates for dementia prevalence were included in a cost model based on published European CoI papers. For countries where no CoI figures were available, imputation was used.

RESULTS

The total CoI of dementia in the EU27 in 2008 was estimated to be €160 billion (€22 000 per demented per year), of which 56% were costs of informal care. The corresponding costs for the whole Europe was €177 billion. In northern Europe, the direct costs are estimated to be considerabe, while the cost of informal care is the major cost component in southern Europe. The sensitivity analysis showed a range for total EU27 costs between €111 and 168 billion.

CONCLUSIONS

The estimated CoI in this study is higher than in previous studies. There are also large differences in different European regions. Notwithstanding the methodological challenges, the societal costs of dementia in Europe are very high which in turn have substantial resource impacts on the social and health care systems in Europe.

Alzheimer's disease: the strength of association of costs with different measures of disease severity

OBJECTIVE

To identify Alzheimer's disease (AD) severity measures for use in cost-effectiveness models that effectively capture the impact of AD on costs.

METHODS

A review of the literature and data abstraction from papers that present 1) mean AD costs (direct, indirect, or total) by disease severity, defined using measure of cognition, functional status, and behavior; and/or 2) the results of regression analyses that estimate the strength of the association between AD costs and disease severity.

RESULTS

All papers reviewed showed that mean total costs increase with disease severity regardless of severity-measurement method. The relative difference in mean total costs between patients with severe disease compared to those with moderate disease, or moderate disease compared to mild disease, was fairly consistent across studies, suggesting that any of the disease-severity measures may be used to broadly categorize patients by cost. However, when regression analysis included multiple disease-severity measures, independent associations with costs were noted for the different measures. Cognitive and functional status measures were consistently associated with direct costs, whereas functional status and behavioral measures were consistently associated with indirect costs and caregiver hours.

CONCLUSIONS

Either multidimensional disease-severity measures, or a single disease-severity measure, that capture the impact of cognition, functional status, and behavior on costs are needed for cost-effectiveness models.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Association between subjective memory complaints and health care utilisation: a three-year follow up

Background

Subjective memory complaints (SMC) are common among elderly patients and little is know about the association between SMC and health care utilisation. Thus, the aim of this study was to investigate health care utilisation during a three-year follow-up among elderly patients consulting their general practitioner and reporting subjective memory complaints (SMC).

Methods

This study was conducted as a prospective cohort survey in general practice with three-year follow-up. Selected health care utilisation or costs relative to SMC adjusted for potential confounders were analyzed in a two-part model where the incidence of use of a selected health care service were analyzed separately from the quantity of use for those that use the service. The former analyzed in a Poisson regression approach, the latter in a generalized linear regression model.

Results

A total 758 non-nursing home residents aged 65 years and older consulted their GP in October and November 2002 and participated in the present study. The adjusted probability of nursing home placement was significantly increased in subjects with SMC relative to subjects without SMC (RR = 2.3). More generally, SMC was associated with an increase in the cost of selected health care utilisation of 60% over three years (p = 0.003).

Conclusion

The data of this study indicated that in an elderly primary care population the presence of SMC increased the cost of health care utilisation by 60% over three years. Thus, inquiry into SMC may contribute to a risk profile assessment of elderly patients and may identify patients with an increased use of health care services.

The cost of dementia in Europe: a review of the evidence, and methodological considerations

Alzheimer's disease (AD) is a leading cause of disability in the elderly, leading to a high burden on caregivers and costs to society. This article describes the current level of data availability regarding the costs of AD in Europe, summarizes and compares findings from previous studies in different countries, and discusses the applicability of available data for modelling purposes. A literature review was conducted for papers in any language reporting data on costs of care for patients with diagnosed dementia or possible/probable AD. Only papers reporting patient-level data on costs were included. A total of 16 studies were identified: from the Nordic region (4), the UK (3), Spain (3), France (2), Italy (2), Belgium (1) and Germany (1). There is large variation in total cost estimates, depending on, for example, differences in study methodology, setting, type and severity of patients included, range of costs assessed and the choice of principle for valuing informal care. The median value for total annual care costs in all studies was Euro28 000 (range Euro6614-Euro64 426) [year 2005 values]. Few studies assessed aspects of disease severity other than cognitive function. The costs of AD in Europe are substantial and increase with disease severity. Methodological differences between studies make comparison across countries and healthcare systems difficult, and there is a need to standardize methods for assessing and valuing informal care. Patient-level information on resource use is required to analyse determinants of care costs and predict the impact of therapeutic interventions. More data are needed to support future economic evaluations of therapies for AD.

Direct costs associated with mild cognitive impairment in primary care

BACKGROUND/AIMS

Little is known about the direct costs of individuals with Mild Cognitive Impairment (MCI). This study investigates the direct costs associated with MCI according to recent diagnostic criteria from a societal perspective.

METHODS

Four hundred and fifty-two primary care patients aged 75+ from Leipzig, Germany, were investigated in face-to-face interviews regarding MCI according to the current diagnostic criteria of the International Working Group on MCI, resource utilisation and costs (questionnaire of service utilisation and costs), as well as chronic medical illness (Chronic Disease Score). Resource utilisation was monetarily valued using 2004/2005 prices.

RESULTS

Mean annual direct costs were 4,443 euro for patients with MCI (n=39) and 3,814 euro for patients without MCI (n=413) (p=0.34). Looking at the cost components, patients with and without MCI only significantly differed regarding pharmaceutical costs (1,210 euro vs 1,062 euro; p<0.05) not caused by antidementive drugs.

CONCLUSION

Direct costs of individuals having MCI are not significantly increased in comparison to direct costs of individuals without cognitive deficits.

Time use and costs of institutionalised elderly persons with or without dementia: results from the Nordanstig cohort in the Kungsholmen Project--a population based study in Sweden

BACKGROUND

The aging of the population has become a worldwide phenomenon. This leads to increased demand for services and with limited resources it is important to find a way to estimate how resources can be match to those with greatest need.

AIMS

To analyse time use and costs in institutional care in relation to different levels of cognitive and functional capacity for elderly persons.

METHODS

The population consisted of all institutionalised inhabitants, 75 + years, living in a rural community (n = 176). They were clinically examined by physicians and interviewed by nurses. Staff and informal care-giving time was examined with the RUD (Resource Utilization in Dementia) instrument.

RESULTS

Tobit regression analyses showed that having dementia increased the amount of ADL care time with 0.9 h when compared to those not having dementia, whereas each loss of an ADL function (0-6) added 0.6 h of ADL care time. Analysing the total care time use, the presence of dementia added more than 9 h, while each loss of one ADL function added 2.9 h. There were some informal care contributions, however with no correlation to severity in dependency. The estimated cost for institutional care increased with more than 85% for people being dependent in 5-6 ADL activities compared to persons with no functional dependency, and with 30% for persons with dementia compared to the non-demented.

CONCLUSION

There is a variation in time use in institutional settings due to differences in ADL dependency but also whether dementia is present or not. This variation has implications for costs of institutional care.

An estimate of the worldwide prevalence and direct costs of dementia in 2003

Dementia disorders are today considered to be a major driver of costs in health care and social systems and worrying estimates of future dementia prevalence have been presented. It is of great interest for policy makers to have an estimate of dementia disorders' contribution to global social and health care costs, particularly in light of the demographic prognoses. The worldwide costs of dementia were estimated from prevalence figures for different regions, and cost-of-illness studies from key countries using a model based on the relationship between direct costs of care per demented and the gross domestic product per capita in each country. The worldwide direct costs for dementia in 2003 are estimated at 156 billion USD in the main scenario based on a worldwide prevalence of 27.7 million demented persons (sensitivity analysis: 129-159 billion USD). Ninety-two percent of the costs are found in the advanced economies with 38% of the prevalence. Although there are several sources of uncertainty, it is obvious that the worldwide costs are substantial and the expected increase in elderly people in the developing countries presents a great challenge.

Determinants of costs of care for patients with Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD), the most common cause of dementia, is a major cause of disability and care burden in the elderly. This study aims to estimate the costs of formal and informal care and identity determinants of care costs.

MATERIALS AND METHODS

Two hundred and seventy-two (AD) patients and their caregivers were recruited among patients attending regular visits at six memory clinic in Sweden, Denmark, Norway and Finland. Patients with a diagnosis of AD and with an identifiable primary caregiver were eligible for inclusion. Data was collected by questionnaires at baseline, and at scheduled follow-up visits after 6 months and again after 12 months. Cognitive function was assessed with the Mini Mental State Examination (MMSE) and behavioural disturbances were measured using a brief version of the neuropsychiatric inventory (NPI).

RESULTS

Total annual costs were on average 172,000 SEK, ranging from 60,700 SEK in mild dementia to 375,000 SEK in severe dementia. Costs for community care (special accommodation, home help, etc.) constituted about half of total costs of care and increase sharply with increasing cognitive impairment. Informal care costs, valued at the opportunity cost of the caregiver's time, make up about a third of total costs and also increased significantly with disease severity. Medical care costs (inpatient care, outpatient care, pharmaceuticals), on the other hand, were not significantly related to disease severity. Regression analysis confirmed a strong association between costs and cognitive function, between patients as well as within patients over time. There was also a significant influence on costs from behavioural disturbances. Sensitivity analysis showed that the method chosen to value informal care can have considerable impact on results.

CONCLUSIONS

Costs of care in patient with AD are high and related to dementia severity as well as presence of behavioural disturbances. The cost estimates presented have implications for future economic evaluation of treatments for Alzheimer's disease.

A Systematic Review of the Clinical and Cost-Effectiveness of Memantine in Patients with Moderately Severe to Severe Alzheimer???s Disease

Alzheimer's disease (AD) is the most common form of dementia and is characterised by a worsening of cognition, functional ability, and behaviour and mood. The objective of this study was to review the clinical and cost-effectiveness of memantine for the treatment of patients with moderately severe to severe AD. To achieve this, a systematic search and review of the clinical and cost effectiveness literature for memantine was undertaken. The literature search covered the period from the inception of MEDLINE, Cochrane Library, EMBASE and other electronic databases until July 2004. The search included randomised controlled trials (RCTs) and full economic evaluations that assessed the use of memantine in patients with moderately severe to severe AD. Two published RCTs were included in this review; in one of these trials the participants were already being treated with donepezil. The two RCTs showed benefit for patients receiving memantine compared with placebo on the outcome measures of the Alzheimer's Disease Cooperative Study Activities of Daily Living Inventory modified for severe dementia, the Clinician's Interview-Based Impression of Change Plus Caregiver Input, and the Severe Impairment Battery, and that memantine appeared to be slightly more effective in patients already receiving a stable dose of donepezil. Five cost-effectiveness studies were included in the review. Although these studies reported cost reductions and improved outcomes with memantine, the evaluations were based on a number of assumptions. In conclusion, memantine appears to be beneficial when assessed using functional and global measurements. However, the effect of memantine on cognitive scores and behaviour and mood outcomes is less clear. Cost-effectiveness is dependent upon assumptions surrounding clinical effect and context-specific cost data.

Prevalence, resource utilization and costs of vascular dementia compared to Alzheimer's dementia in a population setting

OBJECTIVES

To determine the prevalence of dementia and to measure the monetary impact and health resources utilization of vascular dementia (VD) compared to Alzheimer's dementia (AD) in persons aged over 64 years in a population setting.

METHODS

Retrospective, cross-sectional study. In the initial phase, information was obtained on specific clinical characteristics from the subjects with an active diagnosis of dementia. The second phase consisted of a clinical evaluation and validation of the cases. Mini-Mental State Examination was used to assess cognitive impairment. Dementia and its subtypes were determined using established diagnostic criteria. Information was obtained on the use of health care resources (direct costs) and the number of hours devoted by the primary caregiver (indirect costs) for patients with a documented diagnosis of AD or VD within the last 6 months prior to the interview. A multiple logistic regression analysis was performed to correct the model.

RESULTS

A total of 6,004 subjects were analyzed, 258 with diagnosis of dementia (overall prevalence: 4.3%). An evaluation was made of 224 patients, and gross prevalence of AD and VD was 2.4 and 1.0%, respectively. Cost per patient per semester was EUR 8,086 for AD and EUR 11,039 for VD (p = 0.016). 85.5% of the cost was attributable to primary caregiver time in AD and 84.4% in VD.

CONCLUSIONS

The prevalence of AD and VD increases with age. No sociodemographic differences were seen between AD and VD. Costs associated with health care resource and primary caregiver utilization were high, being higher in VD than in AD.

Cost of Alzheimer's disease in a developing country setting

PURPOSE

To evaluate the economic impact of AD in Denizli, Turkey.

DESIGN AND METHODS

This observational study was conducted with 42 AD patients and their primary caregivers. During the initial interview, demographic data and medical histories were collected with questionnaires. For an observational period of 15 days, data on time spent for patient care were collected using standard forms. Calculations on direct cost (e.g. per day medication, outpatient physician visits during the last 3 months), indirect cost (e.g. time spent for care by caregiver for daily living (ADL) and instrumental activity of daily living (IADL)) were made by summing up and taking averages of the appropriate items. ANOVA, and linear regressions were the methods for comparisons.

RESULTS

The primary caregivers of the patients mainly were their children and/or spouses. The maximum mean time spent (h/week) was 21.0 (17.5) for severely damaged cognition. The average annual cost per case was between $1,766 [95% Confidence Intervals (CI); 1.300-2.231] and $4,930 (95% CI; 3.3714-6.147). The amount of caregiver cost was the most significant item in the overall cost and it showed an increase with the declining cognitive function of patients. Daily medication cost reflected the same pattern. In contrast, cost of outpatient physician was the lowest among the patients with the worst cognition.

CONCLUSIONS

These results suggest that recently AD has become a significant cost for developing countries. This pilot study gives an idea of the cost of AD in developing countries where determining the actual cost can be difficult.

Cost-effectiveness of memantine for moderate to severe Alzheimer's disease in Sweden

BACKGROUND

Alzheimer's disease entails enormous costs for society and impairs quality of life for patients and caregivers.

OBJECTIVE

This study estimated the cost-effectiveness of memantine in the treatment of patients with moderately severe to severe cognitive impairment from Alzheimer's disease in Sweden.

METHODS

The study was based on published data from several sources, including a randomized controlled trial of memantine versus placebo and a longitudinal observational study of Alzheimer's disease patients in Sweden. Costs were estimated from the public payer's perspective, including direct costs but excluding costs of informal care, and resource utilization data were taken from the observational study. Cost-effectiveness was quantified as quality-adjusted life-years (QALYs) gained from treatment with the use of previously published utility weights. A Markov simulation model was constructed, incorporating the effect of treatment on cognitive function, physical dependence related to activities of daily living, and institutionalization. Costs and effects for treated and untreated patients were estimated for 5 years (10 cycles). In the base-case analysis, treatment costs were added for 2 years, but the effect on transition probabilities was applied only for the first year of treatment.

RESULTS

Compared with no treatment, memantine treatment was predicted to be associated with lower costs of care, longer time to dependence and institutionalization, and gains in QALYs. Treatment was estimated to decrease formal care costs by 123,600 Swedish kronor (SEK) and, after taking into account the cost of memantine, to lead to net cost savings of 100,528 SEK per patient. Treated patients gained 0.148 QALY over the 5-year simulation.

CONCLUSIONS

From a public payer's perspective, the observed effect of memantine on cognitive and physical function is predicted to translate into economic benefits that offset the added treatment cost. Treatment is also predicted to delay institutionalization, improve independence, and increase QALYs.

Memantine: a pharmacoeconomic review of its use in moderate-to-severe Alzheimer's disease

Memantine (Ebixa, Namenda, Axura) is an uncompetitive NMDA receptor antagonist used in the management of patients with moderate-to-severe Alzheimer's disease. It is currently the only drug approved for use in these more advanced stages of the disease. Significant reductions in functional and cognitive decline have been demonstrated with memantine relative to placebo in randomised, double-blind trials in this patient population. Clinical trial and postmarketing surveillance data indicate that the drug is generally well tolerated. Two fully published modelled cost-effectiveness analyses of memantine in moderate-to-severe Alzheimer's disease have been conducted in the UK and Finland, in which patient progression was simulated through health states related to dependency, residential setting and cognitive function. Although the specific costs included in the analyses varied, as did the study perspective and geographical location, results of the base-case analyses consistently showed that memantine was dominant over no pharmacological treatment. In the UK and Finnish analyses, memantine increased the duration of independence by 1.3 and 4.1 months, respectively, and the time to institutionalisation by 0.8 and 1 month. Mean total per-patient costs were reduced by 1963 pounds over 2 years (2003 costs) in the UK analysis and by 1687 eurossover 5 years (2001 costs) in the Finnish analysis. Memantine was also associated with a small gain in quality-adjusted life expectancy in the UK model. In sensitivity analyses, memantine remained dominant for almost all plausible changes to key variables. Memantine reduced total societal costs by $1090 per patient per month (1999 costs) compared with no pharmacological treatment over 28 weeks in a resource utilisation and cost analysis conducted alongside a pivotal US trial in patients with moderate-to-severe Alzheimer's disease. Results were primarily driven by reductions in total caregiver costs, which included the opportunity cost of time spent in caregiving tasks, and in direct nonmedical costs, which included the cost of care in a nursing home or similar institution.In conclusion, in patients with moderate-to-severe Alzheimer's disease, memantine is associated with significant reductions in functional and cognitive decline compared with no pharmacological treatment. Available pharmacoeconomic data from Europe and the US, despite some inherent limitations, support the use of memantine as a cost-effective treatment in this patient population, although definitive conclusions are not feasible because of limited data.

Impact of donepezil treatment for Alzheimer's disease on caregiver time

OBJECTIVE

To assess the impact of donepezil treatment compared with placebo on caregiver time spent assisting patients with Alzheimer's disease (AD).

RESEARCH DESIGN AND METHODS

Patient and caregiver data were collected as part of a 1-year, prospective, double-blind, randomized, placebo-controlled trial. The Resource Utilization in Dementia (RUD) questionnaire was used to record caregiver time at study baseline and at Weeks 12, 24, 36, and 52. This analysis focuses solely on those caregivers who were actively (> 0 h/day reported on the RUD) providing care at study baseline.

MAIN OUTCOME MEASURES

The change in time relative to baseline that caregivers spent assisting patients over the course of the study.

RESULTS

The active caregiver population was composed of 96 caregivers of donepezil-treated patients and 94 caregivers of patients receiving placebo. Over the course of the 1-year study, and as the condition of the AD patients deteriorated, it was expected that caregiver time would increase. As expected, after 52 weeks, caregivers of placebo patients were providing almost 2 h each day (106.8 min) more care than they had done at study baseline. For those caregivers of donepezil-treated patients, although they were spending more time caring than they had done at study baseline, their time burden had only increased by 42.6 min more each day. This difference in caring time between the 2 groups, relative to baseline at Week 52, was 1.1 h (64.2 min) each day, and was significant (p = 0.03).

CONCLUSION

Caregiver time devoted to helping an AD patient typically increases with the severity of the disease. By helping the patient maintain his/her ability to perform activities of daily living for longer, treatment with donepezil is not only beneficial to the patient, but also has positive time-burden implications for the caregiver.

Cost Effectiveness of Memantine in Alzheimer???s Disease

BACKGROUND

Clinical trials with memantine, an uncompetitive moderate-affinity NMDA antagonist, have shown improved clinical outcomes, increased independence and a trend towards delayed institutionalisation in patients with moderately severe-to-severe Alzheimer's disease. In a randomised double-blind, placebo-controlled, 28-week study conducted in the US, reductions in resource utilisation and total healthcare costs were noted with memantine relative to placebo. While these findings suggest that, compared with placebo, memantine provides cost savings, further analyses may help to quantify potential economic gains over a longer treatment period.

OBJECTIVE

To evaluate the cost effectiveness of memantine therapy compared with no pharmacological treatment in patients with moderately severe-to-severe Alzheimer's disease over a 2-year period.

METHODS

A Markov model was constructed to simulate patient progression through a series of health states related to severity, dependency (determined by patient scores on the Alzheimer's Disease Cooperative Study-Activities of Daily Living [ADCS-ADL] inventory and residential status ('institutionalisation') with a time horizon of 2 years (each 6-month Markov cycle was repeated four times). Transition probabilities from one health state to another 6 months later were mainly derived from a 28-week, randomised, double-blind, placebo-controlled clinical trial. Inputs related to epidemiological and cost data were derived from a UK longitudinal epidemiological study, while data on quality-adjusted life-years (QALYs) were derived from a Danish longitudinal study. To ensure conservative estimates from the model, the base case analysis assumed drug effectiveness was limited to 12 months. Monte Carlo simulations were performed for each state parameter following definition of a priori distributions for the main variables of the model. Sensitivity analyses included worst case scenario in which memantine was effective for 6 months and one-way sensitivity analyses on key parameters. Finally, a subgroup analysis was performed to determine which patients were most likely to benefit from memantine. Informal care was not included in this model as the costs were considered from National Health Service and Personal Social Services perspective.

RESULTS

The base case analysis found that, compared with no treatment, memantine was associated with lower costs and greater clinical effectiveness in terms of years of independence, years in the community and QALYs. Sensitivity analyses supported these findings. For each category of Alzheimer's disease patient examined, treatment with memantine was a cost-effective strategy. The greatest economic gain of memantine treatment was in independent patients with a Mini-Mental State Examination score of > or =10.

CONCLUSION

This model suggests that memantine treatment is cost effective and provides cost savings compared with no pharmacological treatment. These benefits appear to result from prolonged patient independence and delayed institutionalisation for moderately severe and severe Alzheimer's disease patients on memantine compared with no pharmacological treatment.

Cost of dementia: impact of disease progression estimated in longitudinal data

AIMS

Several studies have shown that health care costs are higher for demented than for non-demented persons and that health care costs are higher for more severe demented persons than less severe demented persons. However, most studies report on cross-sectional study designs, and thus fail to examine the influence of disease progression on changes in health care costs to individual persons. The objective of this study was, using longitudinal data, to examine changes in total health care costs with disease progression in demented persons.

METHODS

We assumed that disease progression could be characterised by transitions between different states of dementia which reflected the degree to which the disease progressed over time. Then, changes in health care costs were regressed on a set of explanatory variables including disease progression. A total of 465 demented and non-demented persons were interviewed twice. The time between interviews was about three years. Before each interview, the participant was examined for dementia and classified by type of dementia (Alzheimer's disease, vascular or other types of dementia) and degree of dementia (very mild, mild, moderate, severe).

RESULTS

The results of this longitudinal study confirmed that health care costs increased over time for non-demented as well as for demented persons and that health care costs increased with disease progression. In particular, the health care costs increased when the disease had progressed into the severe state of the dementia. Also, decline in functional abilities was an important factor for explaining changes in health care costs.

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

PURPOSE

The goal of this literature review was to determine the validity and policy relevance of recent estimates from many countries of Alzheimer's disease (AD) costs.

DESIGN AND METHODS

We searched Medline and other databases for English-language peer-reviewed journals on total, direct, indirect, and per case cost of AD that used 1985-2000 data. We adjusted costs of U.S. studies for inflation. We adjusted non-U.S. studies by that country's medical cost inflation rate and purchasing power parity (PPP).

RESULTS

Of 71 studies identified, 21 met all criteria for inclusion. Annual inflation adjusted U.S. total costs of AD varied from $5.6 billion to $88.3 billion. AD total per case (direct and indirect) costs varied from $1,500 to $91,000; indirect/family costs varied from $3,700 to $21,000. Among non-U.S. studies, AD annual adjusted per case costs varied from PPP $2,300 to PPP $30,000. Cost variation was due to diverse study methods, data sources, services included, and lack of clear differentiation between cost of AD and cost of caring for people with AD.

IMPLICATIONS

The cost of AD is high, although reliable estimates are not available. Costs are likely to rise given expected demographic shifts in all countries. The widely variable cost estimates call into question the real costs of Alzheimer's disease and their applicability to policy initiatives.

The economics of Alzheimer disease

Economic assessments of health and healthcare have become an integral part of policy decisions in the last decade. Increasingly, this trend is extending to medical decision-making in day-to-day patient-provider interactions. Alzheimer disease (AD) offers a potent example of the clinical and economic issues at stake with its diagnostic techniques, pharmacotherapies, and public health and policy implications. This review introduces basic economic concepts in examining the impact of AD and related care. It presents a summary of the latest economics research on cost estimates of AD and on economic evaluations of diagnostic and management interventions in terms of cost-of-illness and cost-effectiveness studies respectively. Empirical and conceptual issues about the interpretation of costs and the uses of evaluative methods are also discussed. We found that the economic costs attributable to AD care is highly variable mostly due to non-standardised methodologies and geographical variations in care patterns. There is, however, little doubt that the impact is substantial and is expected to worsen with the demographic, epidemiologic, technologic and economic transitions worldwide. There are comparatively fewer studies on the cost-effectiveness of interventions in AD. Most of the published work revolves around pharmacotherapeutics while relatively little has been done on diagnostics, patient care programmes and programmes for caregivers. We conclude that there are significant opportunities to strengthen research on standardised cost-of-illness analyses and new cost-effectiveness studies on a broader range of AD interventions.

Pharmacoeconomics of cholinesterase inhibitors in the treatment of Alzheimer's disease

Cholinesterase inhibitors constitute one of few treatment options available for Alzheimer's disease, the most common cause of dementia. The modest effects and relatively high acquisition costs of these drugs make the health economics of dementia an important subject of study. Simulation models can be used to bring together existing data and make predictions of the long-term cost effectiveness of treatment. Most models have been built around cognitive function as a key parameter based on the observed relationship between cognitive function and costs of care. Patients with more severe disease attain higher total costs of care. Also, these patients have a higher share of formal care costs than do patients with mild disease, who are usually looked after by informal caregivers. The valuation of unpaid care is controversial, and the choice of method may affect results considerably. Another important issue is the measurement of health-related QOL in patients with Alzheimer's disease. The few existing studies have used proxy respondents to elicit utility weights in different disease states; however, this methodology has not been validated. It is likely that the increased drug costs incurred by the use of cholinesterase inhibitors will be offset (at least partly) by savings in other healthcare costs. However, these results should be viewed as preliminary, since we are still awaiting data from long-term follow-up studies. Also, the value of treatment for patients and caregivers in terms of QOL improvements has yet to be established.

"Value for money" in treating Alzheimer's disease with the new cholinesterase inhibitors

The absolute number of dementia cases is likely to increase due to the impending demographic changes. Several cost-of-illness studies of Alzheimer's disease, mainly from a societal perspective in developed countries, have demonstrated a huge economic burden. A substantial component of this huge economic burden is the direct costs of institutionalization and the indirect cost incurred by informal carers. This huge economic burden is of great interest because of the emergence of several cholinesterase inhibitors with proven efficacy in the treatment of Alzheimer's disease. Several cost-effectiveness studies of these drugs, based mainly on Markov modelling techniques and using data from population-based epidemiological studies and efficacy trials, have indicated that these drugs are cost-effective. A theoretical delay in placement into a residential or a nursing home and consequent cost savings may explain this cost-effectiveness. In the UK, although health authorities would fund the prescription of these drugs, social services would benefit from the cost savings; thus there is little financial incentive for health authorities to fund these drugs.

Is mental health economics important in geriatric psychiatry in developing countries?

BACKGROUND

limited healthcare budgets and a seamless demand for resources suggests that a formula for allocating resources is needed. Economic evaluation can assist in developing this formula.

METHOD

mental health economic studies (cost minimisation, cost-effectiveness, cost-utility, cost-benefit and cost of illness analysis) in geriatric psychiatry from developed and developed countries were examined along with all mental health economic studies in developed countries.

RESULTS

there were no health economic studies in geriatric psychiatry from developing countries against a background of many such studies in developed countries. There were a greater number of health economic studies in other areas of psychiatry in developing countries. Several reasons for the paucity of such studies, the feasibility of undertaking these studies and their significance are discussed.

CONCLUSION

mental health economic studies in geriatric psychiatry in developing countries are feasible, realistic and may well have an important part to play in the allocation of resources. Also, data sets necessary for such studies are emerging from many developing countries.

The costs of caring: medical costs of Alzheimer's disease and the managed care environment

This review summarizes the medical costs associated with Alzheimer's disease (AD) and related dementias, as well as the payers responsible for these medical costs in the US health care system. It is clear from this review that AD and related dementias are associated with substantial medical costs. The payers responsible for a majority of these costs are families of patients with AD and the US government through the Medicare and Medicaid programs. In an attempt to control expenditures, Medicare and Medicaid have turned to managed care principles and managed care organizations. The increase in "managed" dementia care gives rise to several potential problems for patients with AD, along with many opportunities for systematic improvement in the quality of dementia care. Evidence-based disease management programs provide the greatest opportunities for improving managed dementia care but will require the development of dementia-specific quality of care measures to evaluate and continually improve them.

Clinical and economic factors in the treatment of behavioural and psychological symptoms of dementia

The prevalence of behavioural and psychological symptoms of dementia (BPSD) exceeds 50%. They cause distress to patients and caregivers, increase resource utilisation of various kinds, and form a high risk for accelerated psychiatric care through institutionalisation. Although evidence for current pharmacological treatment is not strong and the construct of BPSD is still not very clear, future aspects of treatment of BPSD may be positive. If we look at overall success rates of the antipsychotics, the traditional antipsychotics have the highest combined success rate of 63.1%, whereas the novel antipsychotics have an overall success rate of 56.1%. Haloperidol is the drug with the highest success rate of 65.4%, although this drug is associated with parkinsonian adverse drug reactions. Newer antipsychotics show promise in treating BPSD, but more convincing evidence (e.g. from randomised clinical trials) is required. We provide an overview of the clinical, epidemiological and economic aspects of BPSD and a review of the available literature on their pharmacological treatment. Although only 1 pharmacoeconomic study has been conducted on BPSD, it seems likely that these manifestations drastically increase the burden of dementia.

Medicare expenditures associated with Alzheimer disease

This study uses 4 years of data from the Medicare Current Beneficiary Survey to compare the use of Medicare covered services for persons who report having a diagnosis of dementia or Alzheimer disease with those who do not, adjusting for the prevalence of comorbidities and functional limitations. Although overall rates of Medicare spending are higher for demented persons, when other factors such as functional status are included in the predictive model, there is no consistent relation between the presence of dementia and higher Medicare spending. In some years, dementia was associated with higher adjusted expenditures for community living persons, whereas nursing home residents with Alzheimer disease have lower Medicare expenditures.

Cost function estimation: the choice of a model to apply to dementia

Statistical analysis of cost data is often difficult because of highly skewed data resulting from a few patients who incur high costs relative to the majority of patients. When the objective is to predict the cost for an individual patient, the literature suggests that one should choose a regression model based on the quality of its predictions. In exploring the econometric issues, the objective of this study was to estimate a cost function in order to estimate the annual health care cost of dementia. Using different models, health care costs were regressed on the degree of dementia, sex, age, marital status and presence of any co-morbidity other than dementia. Models with a log-transformed dependent variable, where predicted health care costs were re-transformed to the unlogged original scale by multiplying the exponential of the expected response on the log-scale with the average of the exponentiated residuals, were part of the considered models. The root mean square error (RMSE), the mean absolute error (MAE) and the Theil U-statistic criteria were used to assess which model best predicted the health care cost. Large values on each criterion indicate that the model performs poorly. Based on these criteria, a two-part model was chosen. In this model, the probability of incurring any costs was estimated using a logistic regression, while the level of the costs was estimated in the second part of the model. The choice of model had a substantial impact on the predicted health care costs, e.g. for a mildly demented patient, the estimated annual health care costs varied from DKK 71 273 to DKK 90 940 (US$ 1 = DKK 7) depending on which model was chosen. For the two-part model, the estimated health care costs ranged from DKK 44714, for a very mildly demented patient, to DKK 197 840, for a severely demented patient.

The Scandinavian Multi-Infarct Dementia Trial: a double-blind, placebo-controlled trial on nimodipine in multi-infarct dementia

Vascular dementia is a major cause of mental and physical disability in Western countries. Treatment of vascular dementia is currently based on the recognition and control of vascular risk factors, while specific drugs have not been approved yet. The aim of the present multinational, double-blind, placebo-controlled study was to evaluate the safety and efficacy of nimodipine administered for as long as 26 weeks in improving cognition or slowing cognitive deterioration in patients defined as having multi-infarct dementia (DSM-III-R criteria). Two hundred and fifty-nine patients were included (128 nimodipine, 131 placebo), and 251 were available for the intention-to-treat analysis. No significant difference between drug-treated and placebo patients was noted on the Gottfries-Brâne-Steen scale score (primary efficacy criterion), the remaining neuropsychological tests (Zahlen-Verbindungs-Test, Fuld-Object-Memory Evaluation, Word Fluency Test, Digit Span, Mini-Mental State Examination), and the functional scales (index of Activity of Daily Living, Instrumental Activity of Daily Living, Rapid Disability Scale, Clinical Dementia Rating), although the majority of changes were in favor of the active drug group. A lower incidence of cerebrovascular and cardiac events was observed in the nimodipine-treated patients in comparison with the placebo group. This study failed to show a significant effect of nimodipine on cognitive, social or global assessments in patients defined as affected by multi-infarct dementia according to the DSM-III-R criteria. A post-hoc analysis (presented in an accompanying paper) suggests that nimodipine may have a favorable effect in the subgroup of patients defined as affected by subcortical (small vessel) vascular dementia.