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

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

Cost of care for Alzheimer's disease and related dementias in the United States: 2016 to 2060

Medical and long-term care for Alzheimer's disease and related dementias (ADRDs) can impose a large economic burden on individuals and societies. We estimated the per capita cost of ADRDs care in the in the United States in 2016 and projected future aggregate care costs during 2020-2060. Based on a previously published methodology, we used U.S. Health and Retirement Survey (2010-2016) longitudinal data to estimate formal and informal care costs. In 2016, the estimated per patient cost of formal care was $28,078 (95% confidence interval [CI]: $25,893-$30,433), and informal care cost valued in terms of replacement cost and forgone wages was $36,667 ($34,025-$39,473) and $15,792 ($12,980-$18,713), respectively. Aggregate formal care cost and formal plus informal care cost using replacement cost and forgone wage methods were $196 billion (95% uncertainty range [UR]: $179-$213 billion), $450 billion ($424-$478 billion), and $305 billion ($278-$333 billion), respectively, in 2020. These were projected to increase to $1.4 trillion ($837 billion-$2.2 trillion), $3.3 trillion ($1.9-$5.1 trillion), and $2.2 trillion ($1.3-$3.5 trillion), respectively, in 2060.

Healthcare utilization prior to a diagnosis of young-onset Alzheimer's disease: a nationwide nested case-control study

OBJECTIVE

Our aim was to identify changes in healthcare utilization prior to a young-onset Alzheimer's disease diagnosis.

METHODS

In a retrospective incidence density matched nested case-control study using national health registers, we examined healthcare utilization for those diagnosed with young-onset Alzheimer's disease in Danish memory clinics during 2016-2018 compared with age- and sex-matched controls. Negative binomial regression analysis produced contact rate ratios.

RESULTS

The study included 1082 young-onset Alzheimer's disease patients and 3246 controls. In the year preceding diagnosis, we found increased contact rate ratios for all types of contacts except physiotherapy. Contact rate ratios for contacts with a general practitioner were significantly increased also > 1-5 and > 5-10 years before diagnosis. The highest contact rate ratios were for psychiatric emergency contacts (8.69, 95% CI 4.29-17.62) ≤ 1 year before diagnosis.

INTERPRETATION

Results demonstrate that young-onset Alzheimer's disease patients have increased healthcare utilization from 5 to 10 years prior to diagnosis. Awareness of specific alterations in health-seeking behaviour may help healthcare professionals provide timely diagnoses.

Progressive supranuclear palsy's economical burden: the use and costs of healthcare resources in a large health provider in Israel

BACKGROUND

Progressive supranuclear palsy (PSP) is a rare and fatal neurodegenerative movement disorder with no disease modifying therapy currently available. Data on the costs associated with PSP are scarce. This study aims to assess the direct medical expenditure of patients with PSP (PwPSP) throughout disease course.

METHODS

This retrospective cohort study is based on the data of a large state-mandated health provider in Israel. We identified PwPSP who were initially diagnosed between 2000 and 2017. Each PwPSP was randomly matched to three health-plan members without PSP by birth-year, sex, and socioeconomic status. Healthcare resources' utilization and related costs were assessed.

RESULTS

We identified 88 eligible PwPSP and 264 people in the reference group; mean age at diagnosis was 72.6 years (SD = 8.4) and 53.4% were female. The annual direct costs of PwPSP have risen over time, reaching US$ 21,637 in the fifth year and US$ 36,693 in the tenth year of follow-up vs US$ 8910 in the year prior diagnosis. Compared to people without PSP, PwPSP had substantially higher medical expenditure during the years prior- and post-index date.

CONCLUSION

The present study demonstrates higher economic burden, which increases with time, in PwPSP as compared to those without.

2023 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease, including prevalence and incidence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report examines the patient journey from awareness of cognitive changes to potential treatment with drugs that change the underlying biology of Alzheimer's. An estimated 6.7 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, and Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated by the COVID-19 pandemic in 2020 and 2021. More than 11 million family members and other unpaid caregivers provided an estimated 18 billion hours of care to people with Alzheimer's or other dementias in 2022. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $339.5 billion in 2022. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the paid health care workforce are involved in diagnosing, treating and caring for people with dementia. In recent years, however, a shortage of such workers has developed in the United States. This shortage - brought about, in part, by COVID-19 - has occurred at a time when more members of the dementia care workforce are needed. Therefore, programs will be needed to attract workers and better train health care teams. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2023 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $345 billion. The Special Report examines whether there will be sufficient numbers of physician specialists to provide Alzheimer's care and treatment now that two drugs are available that change the underlying biology of Alzheimer's disease.

Trends in Healthcare Resource Use Preceding Diagnosis of Alzheimer's Disease Dementia

Introduction

An Alzheimer's disease (AD) dementia diagnosis is often preceded by an extended period of cognitive decline. Few studies have examined healthcare resource use (HRU) during an extended period before AD dementia diagnosis.

Methods

In a historical claims-based cohort study, propensity score-matched cohorts of patients with and without AD dementia were observed for a 5-year prediagnosis period and a 1-year postdiagnosis period. Demographics, clinical characteristics, and HRU were compared between groups.

Results

Individuals in the AD dementia group displayed a greater level of medical complexity in the year before diagnosis of AD dementia relative to those in the matched cohort. Both all-cause and AD dementia complication-related HRU increased gradually, with a marked spike at the time of initial AD dementia diagnosis. Discussion. Further research into the natural history of patients with AD dementia is necessary to improve identification of early AD and to better understand its broader impact.

Biologic targets of prescription medications and risk of neurodegenerative disease in United States Medicare beneficiaries

OBJECTIVE

To identify prescription medications associated with a lower risk of three neurodegenerative diseases: Parkinson disease, Alzheimer disease, and amyotrophic lateral sclerosis.

METHODS

We conducted a population-based, case-control study of U.S. Medicare beneficiaries in 2009 (42,885 incident neurodegenerative disease cases, 334,387 randomly selected controls). Using medication data from 2006-2007, we categorized all filled medications according to their biological targets and mechanisms of action on those targets. We used multinomial logistic regression models, while accounting for demographics, indicators of smoking, and health care utilization, to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for 141 target-action pairs and each neurodegenerative disease. For target-action pairs inversely associated with all three diseases, we attempted replication in a cohort study that included an active comparator group. We constructed the cohort by following controls forward for incident neurodegenerative disease from the beginning of 2010 until death or end of 2014, i.e., up to five years after the two-year exposure lag. We used Cox proportional hazards regression while accounting for the same covariates.

RESULTS

The most consistent inverse association across both studies and all three neurodegenerative diseases was for xanthine dehydrogenase/oxidase blockers, represented by the gout medication, allopurinol. Allopurinol was associated with a 13-34% lower risk for each neurodegenerative disease group in multinomial regression, and a mean reduction of 23% overall, as compared to individuals who did not use allopurinol. In the replication cohort we observed a significant 23% reduction for neurodegenerative disease in the fifth year of follow-up, when comparing allopurinol users to non-users, and more marked associations with an active comparator group. We observed parallel associations for a related target-action pair unique to carvedilol.

DISCUSSION/CONCLUSION

Xanthine dehydrogenase/oxidase blockade might reduce risk of neurodegenerative disease. However, further research will be necessary to confirm that the associations related to this pathway are causal or to examine whether this mechanism slows progression.

A Literature Review on the Burden of Alzheimer's Disease on Care Partners

BACKGROUND

Many individuals with Alzheimer's disease (AD) are dependent on nonprofessional care partners. Providing informal care can result in emotional, physical, and financial burdens; however, there is a need for a better understanding of the impact of AD on care partners to support the clinical and economic assessment of potential new treatments.

OBJECTIVE

We conducted a literature review to evaluate the burden experienced by care partners of individuals with AD.

METHODS

Electronic screening and supplementary searches identified studies published from 2011 to 2022 describing the association between AD and the quality of life (QoL) and physical health of care partners, and the economic or financial burden of AD.

RESULTS

Following electronic screening, 62, 25, and 39 studies were included on care partner burden, cost, and healthcare resource use in AD, respectively. Supplementary searches identified an additional 32 studies, resulting in 149 unique studies. These studies showed that care partners of individuals with AD report moderate to severe burden. Higher burden and lower QoL were observed in those caring for individuals with more severe AD. Care partners of individuals with AD experience higher burden, lower QoL, and higher levels of stress, depression, and anxiety than those without caring responsibilities. Informal care costs increased with AD severity and accounted for the greatest proportion of overall societal cost.

CONCLUSIONS

Care partners of individuals with AD experience emotional and economic burden, which increases with AD severity. These impacts should be quantified comprehensively in future studies and captured in economic evaluations of AD interventions.

Hospitalizations in older-adults newly diagnosed with dementia: A population-based longitudinal study in Israel

OBJECTIVES

To compare inpatient burden (i.e. likelihood of hospitalization, number of admissions and length of stay) in persons with newly diagnosed dementia to the general population without dementia. Additionally, to evaluate whether inpatient burden is increased during the years prior to and post dementia diagnosis, and to identify factors associated with increased inpatient burden.

METHOD

The Israeli National Dementia Dataset (2016) was cross-linked with the National Hospital Discharge Database of the Israeli Ministry of Health (2014-2018). Dementia definition was based on documented dementia diagnoses and/or the purchase of medications during 2016. Mixed-effects models were applied to identify demographic and health characteristics associated with inpatient burden in the one and 2 years prior to and after dementia diagnosis.

RESULTS

The dataset included 11,625 individuals aged ≥65 years, identified as incident dementia cases. Compared to the general population of older-adults without dementia, those with newly diagnosed dementia had a higher age-standardized proportion of hospitalizations (26.4% vs. 40%). The odds for hospitalization were highest during the year preceding dementia diagnosis (OR = 3.19, 95% CI 2.51-4.06) compared to 2 years prior to diagnosis, and remained high (although slightly decreased) after dementia diagnosis. Older age was associated with inpatient burden after, but not prior to dementia diagnosis.

CONCLUSIONS

Older persons with dementia are a vulnerable population group with increased utilization of inpatient burden compared to those without dementia, particularly in the years surrounding dementia diagnosis. Sociodemographic risk factors may differ with respect to the time surrounding dementia diagnosis.

Public spending on acute and long-term care for Alzheimer's disease and related dementias

INTRODUCTION

We estimate the spending attributable to Alzheimer's disease and related dementias (ADRD) to the United States government for the first 5 years post-diagnosis.

METHODS

Using data from the Health and Retirement Study matched to Medicare and Medicaid claims, we identify a retrospective cohort of adults with a claims-based ADRD diagnosis along with matched controls.

RESULTS

The costs attributable to ADRD are $15,632 for traditional Medicare and $8833 for Medicaid per dementia case over the first 5 years after diagnosis. Seventy percent of Medicare costs occur in the first 2 years; Medicaid costs are concentrated among the longer-lived beneficiaries who are more likely to need long-term care and become Medicaid eligible.

DISCUSSION

Because the distribution of the incremental costs varies over time and between insurance programs, when interventions occur and the effect on the disease course will have implications for how much and which program reaps the benefits.

Health service use before and after dementia diagnosis: a retrospective matched case-control study

OBJECTIVES

This study investigated patterns in health service usage among older adults with dementia and matched controls over a 10-year span from 5 years before until 5 years after diagnosis.

DESIGN

Population-based retrospective matched case-control study.

SETTING

Administrative health data of individuals in Saskatchewan, Canada from 1 April 2008 to 31 March 2019.

PARTICIPANTS

The study included 2024 adults aged 65 years and older living in the community at the time of dementia diagnosis from 1 April 2013 to 31 March 2014, matched 1:1 to individuals without a dementia diagnosis on age group, sex, rural versus urban residence, geographical region and comorbidity.

OUTCOME MEASURES

For each 5-year period before and after diagnosis, we examined usage of health services each year including family physician (FP) visits, specialist visits, hospital admissions, all-type prescription drug dispensations and short-term care admissions. We used negative binomial regression to estimate the effect of dementia on yearly average health service utilisation adjusting for sex, age group, rural versus urban residence, geographical region, 1 year prior health service use and comorbidity.

RESULTS

Adjusted findings demonstrated that 5 years before diagnosis, usage of all health services except hospitalisation was lower among persons with dementia than persons without dementia (all p<0.001). After this point, differences in higher health service usage among persons with dementia compared to without dementia were greatest in the year before and year after diagnosis. In the year before diagnosis, specialist visits were 59.7% higher (p<0.001) and hospitalisations 90.5% higher (p<0.001). In the year after diagnosis, FP visits were 70.0% higher (p<0.001) and all-type drug prescriptions 29.1% higher (p<0.001).

CONCLUSIONS

Findings suggest the year before and year after diagnosis offer multiple opportunities to implement quality supports. FPs are integral to dementia care and require effective resources to properly serve this population.

Depressive Symptoms and Caregiving Intensity Before and After Onset of Dementia in Partners: A Retrospective, Observational Study

BACKGROUND

Caring for a partner with dementia poses significant emotional burden and high care demands, but changes in impacts before and after dementia onset is unclear.

OBJECTIVE

Examine changes in depressive symptoms and hours of care provided by caregivers through the course of their partners' cognitive decline.

METHODS

Retrospective, observational study using household survey data from 2000-2016 Health and Retirement Study and count models to evaluate older individuals' (ages ≥51 y) depressive symptoms (measured using the shortened Center for Epidemiologic Studies Depression Scale) and weekly caregiving in the 10 years before and after their partners' dementia onset (identified using Telephone Interview Cognitive Status screening). Relationships were examined overall and by sex and race.

RESULTS

We identified 8298 observations for 1836 older caregivers whose partners developed dementia. From before to after partners' dementia onset, caregivers' mean (SD) depressive symptoms increased from 1.4 (1.9) to 1.9 (2.1) ( P <0.001) and weekly caregiving increased from 4.4 (19.7) to 20.8 (44.1) ( P <0.001) hours. Depressive symptoms and caregiving hours were higher for women compared with men. Depressive symptoms were higher for Blacks compared with Whites, while caregiving hours were higher for Whites. The expected count of caregivers' depressive symptoms and caregiving hours increased by 3% ( P <0.001) and 9% ( P =0.001) before partners' dementia onset and decreased by 2% ( P <0.001) and 1% ( P =0.63) following partners' dementia onset. No differences observed by sex or race.

DISCUSSION

Depressive symptoms and instrumental burdens for caregivers increase substantially before the onset of dementia in partners. Early referral to specialty services is critical.

Medicare spending associated with a dementia diagnosis among older adults

BACKGROUND

Over 6 million Americans have Alzheimer's Disease or Related Dementia (ADRD) but whether spikes in spending surrounding a new diagnosis reflect pre-diagnosis morbidity, diagnostic testing, or treatments for comorbidities is unknown.

METHODS

We used the 1998-2018 Health and Retirement Study and linked Medicare claims from older (≥65) adults to assess incremental quarterly spending changes just before versus just after a clinical diagnosis (diagnosis cohort, n = 2779) and, for comparative purposes, for a cohort screened as impaired based on the validated Telephone Interview for Cognitive Status (TICS) (impairment cohort, n = 2318). Models were adjusted for sociodemographic and health characteristics. Spending patterns were examined separately by sex, race, education, dual eligibility, and geography.

RESULTS

Among the diagnosis cohort, mean (SD) overall spending was $4773 ($9774) per quarter - 43% of which was spending on hospital care ($2048). In adjusted analyses, spending increased by $8400 (p < 0.001), or 156%, from $5394 in the quarter prior to $13,794 in the quarter including the diagnosis. Among the cohort in which impairment was incidentally detected using the TICS, adjusted spending did not change from just before to after detection of impairment, from $2986 before and $2962 after detection (p = 0.90). Incremental spending changes did not differ by sex, race, education, dual eligibility, or geography.

CONCLUSION

Large, transient spending increases accompany an ADRD diagnosis that may not be attributed to impairment or changes in functional status due to dementia. Further study may help reveal how treatment for comorbidities is associated with the clinical diagnosis of dementia, with potential implications for Medicare spending.

Development of a machine learning model to predict mild cognitive impairment using natural language processing in the absence of screening

BACKGROUND

Patients and their loved ones often report symptoms or complaints of cognitive decline that clinicians note in free clinical text, but no structured screening or diagnostic data are recorded. These symptoms/complaints may be signals that predict who will go on to be diagnosed with mild cognitive impairment (MCI) and ultimately develop Alzheimer's Disease or related dementias. Our objective was to develop a natural language processing system and prediction model for identification of MCI from clinical text in the absence of screening or other structured diagnostic information.

METHODS

There were two populations of patients: 1794 participants in the Adult Changes in Thought (ACT) study and 2391 patients in the general population of Kaiser Permanente Washington. All individuals had standardized cognitive assessment scores. We excluded patients with a diagnosis of Alzheimer's Disease, Dementia or use of donepezil. We manually annotated 10,391 clinic notes to train the NLP model. Standard Python code was used to extract phrases from notes and map each phrase to a cognitive functioning concept. Concepts derived from the NLP system were used to predict future MCI. The prediction model was trained on the ACT cohort and 60% of the general population cohort with 40% withheld for validation. We used a least absolute shrinkage and selection operator logistic regression approach (LASSO) to fit a prediction model with MCI as the prediction target. Using the predicted case status from the LASSO model and known MCI from standardized scores, we constructed receiver operating curves to measure model performance.

RESULTS

Chart abstraction identified 42 MCI concepts. Prediction model performance in the validation data set was modest with an area under the curve of 0.67. Setting the cutoff for correct classification at 0.60, the classifier yielded sensitivity of 1.7%, specificity of 99.7%, PPV of 70% and NPV of 70.5% in the validation cohort.

DISCUSSION AND CONCLUSION

Although the sensitivity of the machine learning model was poor, negative predictive value was high, an important characteristic of models used for population-based screening. While an AUC of 0.67 is generally considered moderate performance, it is also comparable to several tests that are widely used in clinical practice.

2022 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report discusses consumers' and primary care physicians' perspectives on awareness, diagnosis and treatment of mild cognitive impairment (MCI), including MCI due to Alzheimer's disease. An estimated 6.5 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available. Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States in 2019 and the seventh-leading cause of death in 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. More than 11 million family members and other unpaid caregivers provided an estimated 16 billion hours of care to people with Alzheimer's or other dementias in 2021. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $271.6 billion in 2021. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the dementia care workforce have also been affected by COVID-19. As essential care workers, some have opted to change jobs to protect their own health and the health of their families. However, this occurs at a time when more members of the dementia care workforce are needed. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2022 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $321 billion. A recent survey commissioned by the Alzheimer's Association revealed several barriers to consumers' understanding of MCI. The survey showed low awareness of MCI among Americans, a reluctance among Americans to see their doctor after noticing MCI symptoms, and persistent challenges for primary care physicians in diagnosing MCI. Survey results indicate the need to improve MCI awareness and diagnosis, especially in underserved communities, and to encourage greater participation in MCI-related clinical trials.

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.

Incremental Healthcare Utilization and Cost Burden of Comorbid Insomnia in Alzheimer's Disease Patients

BACKGROUND

Insomnia is associated with worsened clinical outcomes among Alzheimer's disease dementia (AD) patients, increased caregiver burden, and healthcare utilization.

OBJECTIVE

This study aimed to characterize the incremental healthcare burden of insomnia in AD using real-world data.

METHODS

A retrospective observational study was conducted on AD patients selected from the IBM® MarketScan Commercial and Medicare Supplemental Databases. AD patients with claims-based evidence of insomnia were direct matched to a non-insomnia cohort based on demographic factors. Healthcare utilization and associated costs were assessed for a 12-month follow-up period.

RESULTS

A total of 3,500 insomnia AD patients and 9,884 non-insomnia AD patients were analyzed. The insomnia cohort had a higher comorbidity burden at baseline (mean score on Charlson Comorbidity Index 2.5 versus 2.2, p < 0.001) and higher proportions of patients with baseline diagnoses for other conditions including depression: 40%, insomnia cohort versus 25%, non-insomnia (p < 0.001). AD patients with insomnia were more likely to have a claim for inpatient hospitalizations (39.8%versus 32.3%), emergency room services (56.4%versus 48.0%), and skilled-nursing services (42.6%versus 31.9%) (all p < 0.05). Mean total annual healthcare costs during the 12-month follow-up period were significantly higher among AD patients with insomnia as compared to those without. (Mean costs: $37,356 versus $27,990, p < 0.001).

CONCLUSION

AD patients with comorbid insomnia are more likely to use higher-cost healthcare services such as inpatient hospitalization, and skilled nursing, and have higher total healthcare costs. This real-world analysis provides evidence that AD disease management should consider proper treatment of comorbid insomnia due to the incremental burden and cost implications.

Characteristics of Parkinson's Disease in Patients with and without Cognitive Impairment

Background:

Characterizing patients with Parkinson’s disease (PD) and cognitive impairment is important toward understanding their natural history.

Objective:

Understand clinical, treatment, and cost characteristics of patients with PD pre- and post-cognitive impairment (memory loss/mild cognitive impairment/dementia or dementia treatment) recognition.

Methods:

2,711 patients with PD newly diagnosed with cognitive impairment (index) were identified using administrative claims data. They were matched (1:1) on age and gender to patients with PD and no cognitive impairment (controls). These two cohorts were compared on patient characteristics, healthcare resource utilization, and total median costs for 3 years pre- and post-index using Chi-square tests, t-tests, and Wilcoxon rank-sum tests. Logistic regression was used to identify factors predicting cognitive impairment.

Results:

Comorbidity indices for patients with cognitive impairment increased during the 6-year study period, especially after the index. Enrollment in Medicare Advantage Prescription Drug plans vs. commercial (OR = 1.60), dual Medicare/Medicaid eligibility (OR = 1.36), cerebrovascular disease (OR = 1.24), and PD medication use (OR = 1.46) were associated with a new cognitive impairment diagnosis (all p < 0.05). A greater proportion of patients with cognitive impairment had hospitalizations and emergency department visits and higher median total healthcare costs than controls for each year pre- and post-index.

Conclusion:

In patients with PD newly diagnosed with cognitive impairment, comorbidity burden, hospitalizations, emergency department visits, and total costs peaked 1-year pre- and post-identification. These data coupled with recommendations for annual screening for cognitive impairment in PD support the early diagnosis and management of cognitive impairment in order to optimize care for patients and their caregivers.

The Excess Costs of Dementia: A Systematic Review and Meta-Analysis

BACKGROUND

Dementia is one of the costliest diseases for health care systems with growing importance for policy makers.

OBJECTIVE

The aim of this study is to systematically review the current literature of excess cost studies for dementia and to analyze excess costs in a meta-analysis.

METHODS

A systematic literature search was conducted in PubMed, EconLit, NHS-EED, and Cochrane Library. 22 studies were included and assigned to one of three subgroups according to the time period that they analyzed during disease progression: the time of diagnosis, the time between diagnosis and death, and the time prior to death. Excess costs were analyzed using the ratio of means (ROM) and meta-analysis was performed by pooling ROMs in a random effects model.

RESULTS

Total costs were significantly higher for demented persons compared to non-demented persons at the time of diagnosis (ROM: 2.08 [1.71, 2.54], p <  0.00001, I2 = 98%) and in the time period between diagnosis and death (ROM: 2.19 [1.97, 2.44], p <  0.00001, I2 = 100%). The ROM was highest for professional home care (ROM: 4.96 [2.62, 9.40], p <  0.0001, I2 = 88%) and for nursing facilities (ROM: 4.02 [2.53, 6.40], p <  0.00001, I2 = 100%) for the time period between diagnosis and death.

CONCLUSION

This meta-analysis is the first to assess excess costs of dementia by the ROM method on a global scale. We conclude that our findings demonstrate that costs of dementia constitute a substantial economic burden.

Plan switching among Medicare Advantage beneficiaries with Alzheimer's disease and other dementias

INTRODUCTION

Patients with Alzheimer's disease and related dementias (ADRD) face substantial challenges in selecting, and remaining enrolled in, health insurance. Little is known about how patients with ADRD experience the Medicare Advantage (MA) program.

METHODS

We used, hospital, outpatient, and post-acute care data to identify MA beneficiaries with and without ADRD in 2014. Multinomial logit models estimated the percentage of people who disenrolled to traditional Medicare (TM) or switched to a different MA plan in 2015.

RESULTS

Among non-dually eligible beneficiaries, 9.0% (95% confidence interval [CI]: 8.0, 9.1) with ADRD disenrolled while 19.7% (95% CI: 19.6, 19.9) switched plans within MA compared to a disenrollment rate of 4.2% (95% CI: 4.2, 4.2) and switching rate of 22.8% (95% CI: 22.9, 22.8) for persons without ADRD.

DISCUSSION

MA enrollees with ADRD tend to disenroll at substantially higher rates than those without ADRD. This may be indicative of their care needs not being met in the program.

2021 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the challenges of providing equitable health care for people with dementia in the United States. An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available, making Alzheimer's the sixth-leading cause of death in the United States and the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated in 2020 by the COVID-19 pandemic. More than 11 million family members and other unpaid caregivers provided an estimated 15.3 billion hours of care to people with Alzheimer's or other dementias in 2020. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $256.7 billion in 2020. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2021 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $355 billion. Despite years of efforts to make health care more equitable in the United States, racial and ethnic disparities remain - both in terms of health disparities, which involve differences in the burden of illness, and health care disparities, which involve differences in the ability to use health care services. Blacks, Hispanics, Asian Americans and Native Americans continue to have a higher burden of illness and lower access to health care compared with Whites. Such disparities, which have become more apparent during COVID-19, extend to dementia care. Surveys commissioned by the Alzheimer's Association recently shed new light on the role of discrimination in dementia care, the varying levels of trust between racial and ethnic groups in medical research, and the differences between groups in their levels of concern about and awareness of Alzheimer's disease. These findings emphasize the need to increase racial and ethnic diversity in both the dementia care workforce and in Alzheimer's clinical trials.

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.

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.

Assessment of Rural-Urban Differences in Health Care Use and Survival Among Medicare Beneficiaries With Alzheimer Disease and Related Dementia

IMPORTANCE

There is poor understanding as to how survival and health care use varies among older adults living with Alzheimer disease and related dementia (ADRD) in rural vs urban areas of the United States.

OBJECTIVE

To describe survival and trajectories of hospital, hospice, nursing home, and home health care use among rural and urban Medicare beneficiaries with ADRD in the 6 years after diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study linked Medicare claims data from January 1, 2009, to December 31, 2016, with nursing home and home health assessment data from all US counties. A total of 555 333 Medicare fee-for-service beneficiaries newly diagnosed with ADRD in 2010 were included. A total of 424 561 individuals (76.5%) resided in metropolitan counties, 75 001 (13.5%) in micropolitan counties, and 55 771 (10.0%) in rural counties.

EXPOSURES

Rurality of beneficiary's county of residence.

MAIN OUTCOMES AND MEASURES

Number of days survived after initial ADRD diagnosis; percent of survived days per month spent in the hospital, hospice nursing home, community with home health care services, and community without home health care services.

RESULTS

A total of 555 333 Medicare beneficiaries (mean [SD] age, 82.0 [7.5] years; 345 294 women [62.2%]; 480 286 White [86.5%]) were evaluated. Compared with metropolitan county residents, rural beneficiaries were younger (mean [SD] age, 81.6 [7.6] vs 82.1 [7.5] years), were less likely to be women (34 100 [61.1%] vs 264 688 [62.3%]), were more likely to be White (50 886 [91.2%] vs 361 205 [85.1%]) and Medicaid-eligible (14 264 [25.6%] vs 71 656 [16.9%]), and had fewer preexisting chronic conditions (mean [SD], 6.9 [2.8] vs 7.4 [2.9]). Medicare beneficiaries residing in metropolitan counties survived a mean (SD) of 1183.5 (826.0) days after diagnosis. Adjusting for individual demographic and clinical characteristics, rural and micropolitan county residents survived approximately 1.5 months less than metropolitan residents. The adjusted share of survived days spent in nursing homes was 5.7 (95% CI, 4.0-7.5) percentage points higher for rural vs metropolitan residents. The adjusted share of days in hospitals was 0.7 (95% CI, -0.9 to -0.4) percentage points lower, and the share of days in community without home health care was 4.6 (95% CI, -6.1 to -3.1) percentage points lower for rural vs metropolitan county residents. There were no statistically significant differences in home health or hospice use. Similar patterns were found for micropolitan vs metropolitan residents as for rural vs metropolitan residents, although the magnitude of the differences were smaller. Differences in time spent in community and nursing homes between rural vs metropolitan beneficiaries became more pronounced with further time from diagnosis.

CONCLUSIONS AND RELEVANCE

Study results suggest that, after diagnosis, rural Medicare beneficiaries with ADRD spend more time in nursing homes and less time in the community, receive less home health care, and have shorter survival than their urban counterparts.

Health Care Costs of Alzheimer's and Related Dementias Within a Medicare Managed Care Provider

BACKGROUND

Although one third of Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans, there is limited information about the cost of treating Alzheimer disease and related dementias (ADRD) in these settings.

OBJECTIVE

The objective of this study was to estimate direct health care costs attributable to ADRD among older adults within a large MA plan.

RESEARCH DESIGN

A retrospective cohort design was used to estimate direct total, outpatient, inpatient, ambulatory pharmacy, and nursing home costs for 3 years before and after an incident ADRD diagnosis for 927 individuals diagnosed with ADRD relative to a sex-matched and birth year-matched set of 2945 controls.

SUBJECT

Adults 65 years of age and older enrolled in the Kaiser Permanente Washington MA plan and the Adult Changes in Thought (ACT) Study, a prospective longitudinal cohort study of ADRD and brain aging.

MEASURES

Data on monthly health service use obtained from health system electronic medical records for the period 1992-2012.

RESULTS

Total monthly health care costs for individuals with ADRD are statistically greater (P<0.05) than controls beginning in the third month before diagnosis and remain significantly greater through the eighth month following diagnosis. Greater total health costs are driven by significantly (P<0.05) greater nursing home costs among individuals diagnosed with ADRD beginning in the third month prediagnosis. Although total costs were no longer significantly greater at 8 months following diagnosis, nursing home costs remained higher for the people with dementia through the 3 years postdiagnosis we analyzed.

CONCLUSION

Greater total health care costs among individuals with ADRD are primarily driven by nursing home costs.

Acute Healthcare Utilization of a Multidisciplinary Neurocognitive Dementia Patient Cohort

Background and Purpose

Upon referral from the primary care provider (PCP), dementia is diagnosed either by a neuropsychological evaluation (NPE) or at a multidisciplinary neurocognitive clinic (MNC). Following the NPE, patients continue receiving care from their PCP. In contrast, patients at the MNC are followed by a multidisciplinary care team that provides expertise across specialties in dementia care and education for the patient, family members, and care providers. The purpose of the study was to determine the utilization of acute healthcare services during the 2 years following a diagnosis of dementia in patients from the MNC and NPE.

Methods

A retrospective review was performed of 581 electronic medical records from January 2010 through December 2014 for 2 cohorts of patients diagnosed with dementia 1) by a neuropsychologist or 2) in a MNC. Acute-care hospital admissions, emergency room (ER) visits, and nonroutine PCP visits were identified. Categorical demographics and utilization variables were summarized by frequency. Chi-square analysis was used to analyze demographic characteristics and overall utilization between MNCs and NPE. Utilization in comparison with various demographic characteristics was analyzed using Spearman correlation coefficients and negative binomial regressions.

Results

Patients evaluated in the MNC were older, more severely impaired, and lived alone more often compared with NPE patients, but there was no increase in hospital admissions and ER visits. Patients who underwent NPE were 1.58 times more likely to have a nonroutine PCP office visit than patients evaluated in the MNC (p=0.0093).

Conclusions

Performing follow-up in multidisciplinary clinics provides patients with more education and may help to reduce the utilization of healthcare services.

2020 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the future challenges of meeting care demands for the growing number of people living with Alzheimer's dementia in the United States with a particular emphasis on primary care. By mid-century, the number of Americans age 65 and older with Alzheimer's dementia may grow to 13.8 million. This represents a steep increase from the estimated 5.8 million Americans age 65 and older who have Alzheimer's dementia today. Official death certificates recorded 122,019 deaths from AD in 2018, the latest year for which data are available, making Alzheimer's the sixth leading cause of death in the United States and the fifth leading cause of death among Americans age 65 and older. Between 2000 and 2018, deaths resulting from stroke, HIV and heart disease decreased, whereas reported deaths from Alzheimer's increased 146.2%. In 2019, more than 16 million family members and other unpaid caregivers provided an estimated 18.6 billion hours of care to people with Alzheimer's or other dementias. This care is valued at nearly $244 billion, but its costs extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2020 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $305 billion. As the population of Americans living with Alzheimer's dementia increases, the burden of caring for that population also increases. These challenges are exacerbated by a shortage of dementia care specialists, which places an increasing burden on primary care physicians (PCPs) to provide care for people living with dementia. Many PCPs feel underprepared and inadequately trained to handle dementia care responsibilities effectively. This report includes recommendations for maximizing quality care in the face of the shortage of specialists and training challenges in primary care.

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.

Differences in service utilization at an urban tribal health organization before and after Alzheimer's disease or related dementia diagnosis: A cohort study

INTRODUCTION

The prevalence, mortality, and healthcare impact of Alaska Native and American Indian (ANAI) people with Alzheimer's disease and related dementias (ADRD) are unknown.

METHODS

We conducted a cohort study of electronic health record data that compared healthcare service utilization in patients with and without an ADRD diagnosis. Zero-inflated negative binomial regression with robust standard errors was used to estimate utilization rates.

RESULTS

Compared with patients without ADRD, utilization rates were similar before but higher after ADRD diagnosis. For those with diagnosed ADRD, utilization increased gradually over time with sharp upward change during the year of diagnosis.

DISCUSSION

This is the only study quantifying changes in healthcare service utilization before and after ADRD diagnosis among ANAI people, which is crucial for tailoring geriatric care for ANAI populations.

The effect of nonpharmacologic therapy on global cognitive functions in patients with Alzheimer's disease: an updated meta-analysis of randomized controlled trials

Background: The effectiveness of non-pharmacologic therapy (NPT) in treating the global cognition dysfunction associated with Alzheimer's disease (AD) has not been clearly demonstrated. Therefore, we performed a meta-analysis to address this issue.Methods: The Cochrane Central Register of Controlled Trials, PUBMED, EMBASE and other databases were searched, and outcomes measured by the Mini-Mental State Examination (MMSE) or the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) were analysed.Results: Seven types of NPT were included, 25 randomized controlled trials (RCTs) were selected and 3238 participants were included in the meta-analysis. There were significant differences between the NPT and control groups in the MMSE and ADAS-cog scores.Conclusions: Although more extensive trials need to be performed, NPT has been observed to be beneficial in AD patients.

Prevalence of Aging, Dementia, and Multimorbidity in Older Adults With Down Syndrome

Importance

As the life expectancy of people with Down syndrome (DS) has markedly increased over the past decades, older adults with DS may be experiencing a higher incidence of aging conditions. In addition to longevity, the amyloid precursor protein gene located on chromosome 21 places individuals with DS at a high risk for developing Alzheimer disease. Yet, few studies have determined prevalence of dementia and comorbidities among older people with DS.

Objective

To determine the prevalence of dementia and aging-related comorbidities in older adult individuals with DS.

Design, Setting, and Participants

Cross-sectional analysis of 2015 California Medicare claims data. We examined 1 year of cross-sectional Medicare claims data that included 100% of Californian Medicare beneficiaries enrolled in both Medicare Part A and B in 2015. Of these 3 001 977 Californian Medicare beneficiaries 45 years or older, 878 individuals were identified as having a diagnosis of DS. Data were analyzed between April 2017 and February 2018.

Main Outcomes and Measures

The frequency of DS dementia was assessed across different age categories. The number and frequency of 27 comorbidities were compared among individuals with DS with and without dementia and by age and sex groups.

Results

A total of 353 DS individuals (40%) were identified as having dementia diagnoses (mean, 58.7 years; 173 women [49%]) and 525 without dementia diagnoses (mean, 55.9 years; 250 women [48%]). The frequency of DS dementia among those 65 years or older rose to 49%. The mean number of comorbidities per individual increased with age in general. Comorbid conditions were more numerous among those with dementia compared with those with DS without dementia (mean, 3.4 vs 2.5, respectively), especially among those younger than 65 years. In particular, 4 treatable conditions, hypothyroidism, epilepsy, anemia, and weight loss, were much more frequent in DS dementia.

Conclusions and Relevance

Older Medicare beneficiaries in California with DS, especially those with dementia, have a high level of multimorbidity including several treatable conditions. While DS follow-up has long been confined to the pediatric sphere, we found that longevity in individuals with DS will necessitate complex adult and geriatric care. More evidenced-based and standardized follow-up could support better long-term comorbidity management and dementia care among aging adults with DS.

Cost of dementia in Medicare managed care: a systematic literature review

OBJECTIVES

We conducted a systematic review of studies reporting the direct healthcare costs of treating older adults with diagnosed Alzheimer disease and related dementias (ADRD) within private Medicare managed care plans.

STUDY DESIGN

A systematic review of all studies published in English reporting original empirical analyses of direct costs for older adults with ADRD in Medicare managed care.

METHODS

All papers indexed in PubMed or Web of Science reporting ADRD costs within Medicare managed care plans from 1983 through 2018 were identified and reviewed.

RESULTS

Despite the growth in Medicare managed care enrollment, only 9 papers report the costs of care for individuals with ADRD within these plans, and only 1 study reports data less than 10 years old. This limited literature reports wide ranges for ADRD-attributable costs, with estimates varying from $3738 to $8726 in annual prevalent costs and $8938 to $38,794 in 1-year immediate postdiagnosis incident costs. Reviewed studies also used varied study populations, case and cost ascertainment methods, and analytic methods, making cross-study comparisons difficult.

CONCLUSIONS

The expected continued growth in Medicare managed care enrollment, coupled with the large and growing impact of ADRD on America's healthcare delivery and finance systems, requires more research on the cost of ADRD within managed care. This research should use more consistent approaches to identify ADRD prevalence and provide more detail regarding which components of care are included in analyses and how the costs of care are captured and measured.

Medicare expenditures attributable to dementia

OBJECTIVE

To estimate dementia's incremental cost to the traditional Medicare program.

DATA SOURCES

Health and Retirement Study (HRS) survey-linked Medicare part A and B claims from 1991 to 2012.

STUDY DESIGN

We compared Medicare expenditures for 60 months following a claims-based dementia diagnosis to those for a randomly selected, matched comparison group.

DATA COLLECTION/EXTRACTION METHODS

We used a cost estimator that accounts for differential survival between individuals with and without dementia and decomposes incremental costs into survival and cost intensity components.

PRINCIPAL FINDINGS

Dementia's five-year incremental cost to the traditional Medicare program is approximately $15 700 per patient, nearly half of which is incurred in the first year after diagnosis. Shorter survival with dementia mitigates the incremental cost by about $2650. Increased costs for individuals with dementia were driven by more intensive use of Medicare part A covered services. The incremental cost of dementia was about $7850 higher for females than for males because of sex-specific differential mortality associated with dementia.

CONCLUSIONS

Dementia's cost to the traditional Medicare program is significant. Interventions that target early identification of dementia and preventable inpatient and post-acute care services could produce substantial savings.

Retrospective assessment of patient characteristics and healthcare costs prior to a diagnosis of Alzheimer's disease in an administrative claims database

Background

The objective of this study was to examine patient characteristics and health care resource utilization (HCRU) in the 36 months prior to a confirmatory diagnosis of Alzheimer’s disease (AD) compared to a matched cohort without dementia during the same time interval.

Methods

Patients newly diagnosed with AD (with ≥2 claims) were identified between January 1, 2013 to September 31, 2015, and the date of the second claim for AD was defined as the index date. Patients were enrolled for at least 36 months prior to index date. The AD cohort was matched to a cohort with no AD or dementia codes (1:3) on age, gender, race/ethnicity, and enrollment duration prior to the index date. Descriptive analyses were used to summarize patient characteristics, HCRU, and healthcare costs prior to the confirmatory AD diagnosis. The classification and regression tree analysis and logistic regression were used to identify factors associated with the AD diagnosis.

Results

The AD cohort (N = 16,494) had significantly higher comorbidity indices and greater odds of comorbid mental and behavioral diagnoses, including mild cognitive impairment, mood and anxiety disorders, behavioral disturbances, and cerebrovascular disease, heart disease, urinary tract infections, and pneumonia than the matched non-AD or dementia cohort (N = 49,482). During the six-month period before the confirmatory AD diagnosis, AD medication use and diagnosis of mild cognitive impairment, Parkinson’s disease, or mood disorder were the strongest predictors of a subsequent confirmatory diagnosis of AD. Greater HCRU and healthcare costs were observed for the AD cohort primarily during the six-month period before the confirmatory AD diagnosis.

Conclusion

The results of this study demonstrated a higher comorbidity burden and higher costs for patients prior to a diagnosis of AD in comparison to the matched cohort. Several comorbidities were associated with a subsequent diagnosis of AD.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0920-2) contains supplementary material, which is available to authorized users.

Alzheimer's Disease - Perspective from Political Science: Public Policy Issues

The paper outlines the policy context and summarizes the numerous policy issues that AD raises from the more generic to the unique. It posits that strong public fears of AD and its future prevalence projections and costs, raise increasingly difficult policy dilemmas. After reviewing the costs in human lives and money and discussing the latest U.S. policy initiatives, the paper presents two policy areas as examples the demanding policy decisions we face. The first focuses on the basic regulatory function of protecting the public from those who would exploit these fears. The second centers on the well-debated issues of advance directives and euthanasia that surround AD. Although more dialogue, education and research funding are needed to best serve the interests of AD patients and families as well as society at large, this will be challenging because of the strong feelings and divisions AD engenders.

Economic Burden, Mortality, and Institutionalization in Patients Newly Diagnosed with Alzheimer's Disease

BACKGROUND

Current information is scarce regarding comorbid conditions, treatment, survival, institutionalization, and health care utilization for Alzheimer's disease (AD) patients.

OBJECTIVES

Compare all-cause mortality, rate of institutionalization, and economic burden between treated and untreated newly-diagnosed AD patients.

METHODS

Patients aged 65-100 years with ≥1 primary or ≥2 secondary AD diagnoses (ICD-9-CM:331.0] with continuous medical and pharmacy benefits for ≥12 months pre-index and ≥6 months post-index date (first AD diagnosis date) were identified from Medicare fee-for-service claims 01JAN2011-30JUN2014. Patients with AD treatment claims or AD/AD-related dementia diagnosis during the pre-index period were excluded. Patients were assigned to treated and untreated cohorts based on AD treatment received post-index date. Total 8,995 newly-diagnosed AD patients were identified; 4,037 (44.8%) were assigned to the treated cohort. Time-to-death and institutionalization were assessed using Cox regression. To compare health care costs and utilizations, 1 : 1 propensity score matching (PSM) was used.

RESULTS

Untreated patients were older (83.85 versus 81.44 years; p < 0.0001), with more severe comorbidities (mean Charlson comorbidity index: 3.54 versus 3.22; p < 0.0001). After covariate adjustment, treated patients were less likely to die (hazard ratio[HR] = 0.69; p < 0.0001) and were associated with 20% lower risk of institutionalization (HR = 0.801; p = 0.0003). After PSM, treated AD patients were less likely to have hospice visits (3.25% versus 9.45%; p < 0.0001), and incurred lower annual all-cause costs ($25,828 versus $30,110; p = 0.0162).

CONCLUSION

After controlling for comorbidities, treated AD patients have better survival, lower institutionalization, and sometimes fewer resource utilizations, suggesting that treatment and improved care management could be beneficial for newly-diagnosed AD patients from economic and clinical perspectives.

Nursing Home Use Across The Spectrum of Cognitive Decline: Merging Mayo Clinic Study of Aging With CMS MDS Assessments

BACKGROUND/OBJECTIVES

Objective, complete estimates of nursing home (NH) use across the spectrum of cognitive decline are needed to help predict future care needs and inform economic models constructed to assess interventions to reduce care needs.

DESIGN

Retrospective longitudinal study.

SETTING

Olmsted County, MN.

PARTICIPANTS

Mayo Clinic Study of Aging participants assessed as cognitively normal (CN), mild cognitive impairment (MCI), previously unrecognized dementia, or prevalent dementia (age = 70-89 years; N = 3,545).

MEASUREMENTS

Participants were followed in Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) NH records and in Rochester Epidemiology Project provider-linked medical records for 1-year after assessment of cognition for days of observation, NH use (yes/no), NH days, NH days/days of observation, and mortality.

RESULTS

In the year after cognition was assessed, for persons categorized as CN, MCI, previously unrecognized dementia, and prevalent dementia respectively, the percentages who died were 1.0%, 2.6%, 4.2%, 21%; the percentages with any NH use were 3.8%, 8.7%, 19%, 40%; for persons with any NH use, median NH days were 27, 38, 120, 305, and median percentages of NH days/days of observation were 7.8%, 12%, 33%, 100%. The year after assessment, among persons with prevalent dementia and any NH use, >50% were a NH resident all days of observation. Pairwise comparisons revealed that each increase in cognitive impairment category exhibited significantly higher proportions with any NH use. One-year mortality was especially high for persons with prevalent dementia and any NH use (30% vs 13% for those with no NH use); 58% of all deaths among persons with prevalent dementia occurred while a NH resident.

CONCLUSIONS

Findings suggest reductions in NH use could result from quality alternatives to NH admission, both among persons with MCI and persons with dementia, together with suitable options for end-of-life care among persons with prevalent dementia.

Direct and indirect cost of managing alzheimer's disease and related dementias in the United States

INTRODUCTION

Care of individuals with Alzheimer's Disease and Related Dementias (ADRD) poses special challenges. As the disease progresses, individuals with ADRD require increasing levels of medical care, caregiver support, and long-term care which can lead to substantial economic burden. Areas covered: In this expert review, we synthesized findings from studies of costs of ADRD in the United States that were published between January 2006 and February 2017, highlighted major sources of variation in costs, identified knowledge gaps and briefly outlined directions for future research and implications for policy and program planning. Expert commentary: A consistent finding of all studies comparing individuals with and without ADRD is that the average medical, non-medical, and indirect costs of individuals with ADRD are higher than those without ADRD, despite the differences in the methods of identifying ADRD, duration of the study, payer type and settings of study population. The economic burden of ADRD may be underestimated because many components such as direct non-medical costs for home safety modifications and adult day care services and indirect costs due to the adverse impact of ADRD on caregivers' health and productivity are not included in cost estimates.

Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

OBJECTIVE

The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality.

METHODS

This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study.

RESULTS

Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions.

CONCLUSIONS

This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

2016 Alzheimer's disease facts and figures

This report describes the public health impact of Alzheimer's disease, including incidence and prevalence, mortality rates, costs of care, and the overall impact on caregivers and society. It also examines in detail the financial impact of Alzheimer's on families, including annual costs to families and the difficult decisions families must often make to pay those costs. An estimated 5.4 million Americans have Alzheimer's disease. By mid-century, the number of people living with Alzheimer's disease in the United States is projected to grow to 13.8 million, fueled in large part by the aging baby boom generation. Today, someone in the country develops Alzheimer's disease every 66 seconds. By 2050, one new case of Alzheimer's is expected to develop every 33 seconds, resulting in nearly 1 million new cases per year. In 2013, official death certificates recorded 84,767 deaths from Alzheimer's disease, making it the sixth leading cause of death in the United States and the fifth leading cause of death in Americans age ≥ 65 years. Between 2000 and 2013, deaths resulting from stroke, heart disease, and prostate cancer decreased 23%, 14%, and 11%, respectively, whereas deaths from Alzheimer's disease increased 71%. The actual number of deaths to which Alzheimer's disease contributes is likely much larger than the number of deaths from Alzheimer's disease recorded on death certificates. In 2016, an estimated 700,000 Americans age ≥ 65 years will die with Alzheimer's disease, and many of them will die because of the complications caused by Alzheimer's disease. In 2015, more than 15 million family members and other unpaid caregivers provided an estimated 18.1 billion hours of care to people with Alzheimer's and other dementias, a contribution valued at more than $221 billion. Average per-person Medicare payments for services to beneficiaries age ≥ 65 years with Alzheimer's disease and other dementias are more than two and a half times as great as payments for all beneficiaries without these conditions, and Medicaid payments are 19 times as great. Total payments in 2016 for health care, long-term care and hospice services for people age ≥ 65 years with dementia are estimated to be $236 billion. The costs of Alzheimer's care may place a substantial financial burden on families, who often have to take money out of their retirement savings, cut back on buying food, and reduce their own trips to the doctor. In addition, many family members incorrectly believe that Medicare pays for nursing home care and other types of long-term care. Such findings highlight the need for solutions to prevent dementia-related costs from jeopardizing the health and financial security of the families of people with Alzheimer's and other dementias.

Medicare Expenditures Associated With Hospital and Emergency Department Use Among Beneficiaries With Dementia

Understanding expenditure patterns for hospital and emergency department (ED) use among individuals with dementia is crucial to controlling Medicare spending. We analyzed Health and Retirement Study data and Medicare claims, stratified by beneficiaries' residence and proximity to death, to estimate Medicare expenditures for all-cause and potentially avoidable hospitalizations and ED visits. Analysis was limited to the Medicare fee-for-service population age 65 and older. Compared with people without dementia, community residents with dementia had higher average expenditures for hospital and ED services; nursing home residents with dementia had lower average expenditures for all-cause hospitalizations. Decedents with dementia had lower expenditures than those without dementia in the last year of life. Medicare expenditures for individuals with and without dementia vary by residential setting and proximity to death. Results highlight the importance of addressing the needs specific to the population with dementia. There are many initiatives to reduce hospital admissions, but few focus on people with dementia.

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.

Prepared to care: adult attachment and filial obligation

OBJECTIVES

Past work found that close adult attachment dimension scores predict caregiver preparedness. Theory and past research suggests filial obligation (FO) may mediate the relationship between attachment and caregiver preparedness. The goal of this study was to test that hypothesis.

METHOD

The sample, collected using Mechanical Turk, included 165 women between the ages of 45 and 65 years who were not providing care to an aging parent.  Participants were reimbursed $0.75 for completing an online survey assessing response validity, dimensions of adult attachment, depressive symptomatology, FO, and caregiver preparedness, among other variables. The mean participant age was 52.2 years (SD = 5.5).

RESULTS

The sample was predominantly White/Caucasian (82.6%), and Black/African American (7.3%).  With respect to education, 14.5% completed high school or general education development (GED), 32.7% completed some college, 36.4% completed a Bachelor's degree, and 15.7% completed graduate degrees. The three attachment dimensions (close, dependent, and anxious) and FO were all significantly inner-correlated.  Stepwise multiple regression analyses found that FO fully mediates the relationship between close attachment and caregiver preparedness, even after controlling for age, education, income, depression, and birth order.

CONCLUSION

The primary finding is that FO mediates the relationship between close attachment style and caregiver preparedness among prospective caregivers. This suggests that individual differences in attachment style among prospective caregivers indirectly predict preparedness for future caregiving through FO, suggesting a mechanism relating attachment style and preparation for future care.