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Verghese J, Chalmer R, Stimmel M, Weiss E, Zwerling J, Malik R, Rasekh D, Ansari A, Corriveau RA, Ehrlich AR, Wang C, Ayers E. Non-literacy biased, culturally fair cognitive detection tool in primary care patients with cognitive concerns: a randomized controlled trial. Nat Med 2024:10.1038/s41591-024-03012-8. [PMID: 38834847 DOI: 10.1038/s41591-024-03012-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/22/2024] [Indexed: 06/06/2024]
Abstract
Dementia is often undiagnosed in primary care, and even when diagnosed, untreated. The 5-Cog paradigm, a brief, culturally adept, cognitive detection tool paired with a clinical decision support may reduce barriers to improving dementia diagnosis and care. We performed a randomized controlled trial in primary care patients experiencing health disparities (racial/ethnic minorities and socioeconomically disadvantaged). Older adults with cognitive concerns were assigned in a 1:1 ratio to the 5-Cog paradigm or control. Primary outcome was improved dementia care actions defined as any of the following endpoints within 90 days: new mild cognitive impairment syndrome or dementia diagnoses as well as investigations, medications or specialist referrals ordered for cognitive indications. Groups were compared using intention-to-treat principles with multivariable logistic regression. Overall, 1,201 patients (mean age 72.8 years, 72% women and 94% Black, Hispanic or Latino) were enrolled and 599 were assigned to 5-Cog and 602 to the control. The 5-Cog paradigm demonstrated threefold odds of improvement in dementia care actions over control (odds ratio 3.43, 95% confidence interval 2.32-5.07). No serious intervention-related adverse events were reported. The 5-Cog paradigm improved diagnosis and management in patients with cognitive concerns and provides evidence to promote practice change to improve dementia care actions in primary care.ClinicalTrials.gov: NCT03816644 .
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Affiliation(s)
- Joe Verghese
- Departments of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA.
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Rachel Chalmer
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marnina Stimmel
- Departments of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Erica Weiss
- Departments of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jessica Zwerling
- Departments of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rubina Malik
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David Rasekh
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Asif Ansari
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Roderick A Corriveau
- Department of Neuroscience, National Institute of Neurological Disorders and Stroke, Bethesda, MA, USA
| | - Amy R Ehrlich
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Cuiling Wang
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
- Department of Neuroscience, National Institute of Neurological Disorders and Stroke, Bethesda, MA, USA
| | - Emmeline Ayers
- Departments of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
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Canestaro WJ, Bateman RJ, Holtzman DM, Monane M, Braunstein JB. Use of a Blood Biomarker Test Improves Economic Utility in the Evaluation of Older Patients Presenting with Cognitive Impairment. Popul Health Manag 2024; 27:174-184. [PMID: 38546435 DOI: 10.1089/pop.2023.0309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
More than 16 million Americans living with cognitive impairment warrant a diagnostic evaluation to determine the cause of this disorder. The recent availability of disease-modifying therapies for Alzheimer's disease (AD) is expected to significantly drive demand for such diagnostic testing. Accurate, accessible, and affordable methods are needed. Blood biomarkers (BBMs) offer advantages over usual care amyloid positron emission tomography (PET) and cerebrospinal fluid (CSF) biomarkers in these regards. This study used a budget impact model to assess the economic utility of the PrecivityAD® blood test, a clinically validated BBM test for the evaluation of brain amyloid, a pathological hallmark of AD. The model compared 2 scenarios: (1) baseline testing involving usual care practice, and (2) early use of a BBM test before usual care CSF and PET biomarker use. At a modest 40% adoption rate, the BBM test scenario had comparable sensitivity and specificity to the usual care scenario and showed net savings in the diagnostic work-up of $3.57 million or $0.30 per member per month in a 1 million member population, translating to over $1B when extrapolated to the US population as a whole and representing a 11.4% cost reduction. Savings were driven by reductions in the frequency and need for CSF and PET testing. Additionally, BBM testing was associated with a cost savings of $643 per AD case identified. Use of the PrecivityAD blood test in the clinical care pathway may prevent unnecessary testing, provide cost savings, and reduce the burden on both patients and health plans.
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Affiliation(s)
- William J Canestaro
- Department of Management and Organization, Foster School of Business, University of Washington, Seattle, Washington, USA
| | - Randall J Bateman
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - David M Holtzman
- Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Mark Monane
- C2N Diagnostics, LLC, St. Louis, Missouri, USA
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Garcia RI, Khemka S, Roghani AK, Reddy RP, Pattoor V, Jacob M, Reddy A, Sehar U, Reddy PH. Caring for Individuals with Alzheimer's Disease: A Spotlight on Hispanic Caregivers. J Alzheimers Dis Rep 2024; 8:877-902. [PMID: 38910940 PMCID: PMC11191631 DOI: 10.3233/adr-240035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/18/2024] [Indexed: 06/25/2024] Open
Abstract
A caregiver is a constantly evolving role that an individual most likely undertakes at some point in their lifetime. With discoveries and research in increasing life expectancy, the prevalence of neurological-related diseases, such as Alzheimer's disease (AD) and dementia, is certainly likely to require more caregivers. The demand for AD caregivers is escalating as the prevalence of the disease continues to rise. The projected rise in AD within the Hispanic population in the United States over the next few decades is expected to be the most significant among all ethnic groups. The Hispanic population faces unique dementia risks due to cultural factors like language barriers, lower education, and limited healthcare access. Higher rates of conditions such as diabetes and cardiovascular disease further elevate dementia risk. Family dynamics and caregiving responsibilities also differ, affecting dementia management within Hispanic households. Addressing these distinct challenges requires culturally sensitive approaches to diagnosis, treatment, and support for Hispanic individuals and their family's facing dementia. With AD and other dementia becoming more prevalent, this article will attempt to expand upon the status of caregivers concerning their economic, health, and cultural statuses. We will attempt to focus on the Hispanic caregivers that live in Texas and more specifically, West Texas due to the lack of current literature that applies to this area of Texas. Lastly, we discuss the ramifications of a multitude of factors that affect caregivers in Texas and attempt to provide tools that can be readily available for Hispanics and others alike.
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Affiliation(s)
- Ricardo Isaiah Garcia
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sachi Khemka
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Aryan Kia Roghani
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Frenship High School, Lubbock, TX, USA
| | - Ruhananhad P. Reddy
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Lubbock High School, Lubbock, TX, USA
| | - Vasanthkumar Pattoor
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- University of South Florida, Tampa, FL, USA
| | - Michael Jacob
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Department of Biology, The University of Texas at San Antonio, San Antonio, TX, USA
| | - Aananya Reddy
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Lubbock High School, Lubbock, TX, USA
| | - Ujala Sehar
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - P. Hemachandra Reddy
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Nutritional Sciences Department, College of Human Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Public Health Department of Graduate School of Biomedical Sciences, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Department of Speech, Language and Hearing Services, School Health Professions, Texas Tech University Health Sciences Center, Lubbock, TX, USA
- Department of Pharmacology and Neuroscience, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Zahr NM. Alcohol Use Disorder and Dementia: A Review. Alcohol Res 2024; 44:03. [PMID: 38812709 PMCID: PMC11135165 DOI: 10.35946/arcr.v44.1.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
PURPOSE By 2040, 21.6% of Americans will be over age 65, and the population of those older than age 85 is estimated to reach 14.4 million. Although not causative, older age is a risk factor for dementia: every 5 years beyond age 65, the risk doubles; approximately one-third of those older than age 85 are diagnosed with dementia. As current alcohol consumption among older adults is significantly higher compared to previous generations, a pressing question is whether drinking alcohol increases the risk for Alzheimer's disease or other forms of dementia. SEARCH METHODS Databases explored included PubMed, Web of Science, and ScienceDirect. To accomplish this narrative review on the effects of alcohol consumption on dementia risk, the literature covered included clinical diagnoses, epidemiology, neuropsychology, postmortem pathology, neuroimaging and other biomarkers, and translational studies. Searches conducted between January 12 and August 1, 2023, included the following terms and combinations: "aging," "alcoholism," "alcohol use disorder (AUD)," "brain," "CNS," "dementia," "Wernicke," "Korsakoff," "Alzheimer," "vascular," "frontotemporal," "Lewy body," "clinical," "diagnosis," "epidemiology," "pathology," "autopsy," "postmortem," "histology," "cognitive," "motor," "neuropsychological," "magnetic resonance," "imaging," "PET," "ligand," "degeneration," "atrophy," "translational," "rodent," "rat," "mouse," "model," "amyloid," "neurofibrillary tangles," "α-synuclein," or "presenilin." When relevant, "species" (i.e., "humans" or "other animals") was selected as an additional filter. Review articles were avoided when possible. SEARCH RESULTS The two terms "alcoholism" and "aging" retrieved about 1,350 papers; adding phrases-for example, "postmortem" or "magnetic resonance"-limited the number to fewer than 100 papers. Using the traditional term, "alcoholism" with "dementia" resulted in 876 citations, but using the currently accepted term "alcohol use disorder (AUD)" with "dementia" produced only 87 papers. Similarly, whereas the terms "Alzheimer's" and "alcoholism" yielded 318 results, "Alzheimer's" and "alcohol use disorder (AUD)" returned only 40 citations. As pertinent postmortem pathology papers were published in the 1950s and recent animal models of Alzheimer's disease were created in the early 2000s, articles referenced span the years 1957 to 2024. In total, more than 5,000 articles were considered; about 400 are herein referenced. DISCUSSION AND CONCLUSIONS Chronic alcohol misuse accelerates brain aging and contributes to cognitive impairments, including those in the mnemonic domain. The consensus among studies from multiple disciplines, however, is that alcohol misuse can increase the risk for dementia, but not necessarily Alzheimer's disease. Key issues to consider include the reversibility of brain damage following abstinence from chronic alcohol misuse compared to the degenerative and progressive course of Alzheimer's disease, and the characteristic presence of protein inclusions in the brains of people with Alzheimer's disease, which are absent in the brains of those with AUD.
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Affiliation(s)
- Natalie M Zahr
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California. Center for Health Sciences, SRI International, Menlo Park, California
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5
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2024 Alzheimer's disease facts and figures. Alzheimers Dement 2024; 20:3708-3821. [PMID: 38689398 PMCID: PMC11095490 DOI: 10.1002/alz.13809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
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.
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Moo LR. Longitudinal Management of Dementia in Primary Care. JAMA Intern Med 2024; 184:459-460. [PMID: 38436970 DOI: 10.1001/jamainternmed.2023.8513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
This Viewpoint describes the positive role that primary care teams can play in the lives of patients with dementia and the families that care for them.
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Affiliation(s)
- Lauren R Moo
- New England Geriatric Research, Education and Clinical Center, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts
- Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
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7
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McMurray J, Levy A, Pang W, Holyoke P. Psychometric Evaluation of a Tablet-Based Tool to Detect Mild Cognitive Impairment in Older Adults: Mixed Methods Study. J Med Internet Res 2024; 26:e56883. [PMID: 38640480 PMCID: PMC11069099 DOI: 10.2196/56883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/05/2024] [Accepted: 03/19/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND With the rapid aging of the global population, the prevalence of mild cognitive impairment (MCI) and dementia is anticipated to surge worldwide. MCI serves as an intermediary stage between normal aging and dementia, necessitating more sensitive and effective screening tools for early identification and intervention. The BrainFx SCREEN is a novel digital tool designed to assess cognitive impairment. This study evaluated its efficacy as a screening tool for MCI in primary care settings, particularly in the context of an aging population and the growing integration of digital health solutions. OBJECTIVE The primary objective was to assess the validity, reliability, and applicability of the BrainFx SCREEN (hereafter, the SCREEN) for MCI screening in a primary care context. We conducted an exploratory study comparing the SCREEN with an established screening tool, the Quick Mild Cognitive Impairment (Qmci) screen. METHODS A concurrent mixed methods, prospective study using a quasi-experimental design was conducted with 147 participants from 5 primary care Family Health Teams (FHTs; characterized by multidisciplinary practice and capitated funding) across southwestern Ontario, Canada. Participants included health care practitioners, patients, and FHT administrative executives. Individuals aged ≥55 years with no history of MCI or diagnosis of dementia rostered in a participating FHT were eligible to participate. Participants were screened using both the SCREEN and Qmci. The study also incorporated the Geriatric Anxiety Scale-10 to assess general anxiety levels at each cognitive screening. The SCREEN's scoring was compared against that of the Qmci and the clinical judgment of health care professionals. Statistical analyses included sensitivity, specificity, internal consistency, and test-retest reliability assessments. RESULTS The study found that the SCREEN's longer administration time and complex scoring algorithm, which is proprietary and unavailable for independent analysis, presented challenges. Its internal consistency, indicated by a Cronbach α of 0.63, was below the acceptable threshold. The test-retest reliability also showed limitations, with moderate intraclass correlation coefficient (0.54) and inadequate κ (0.15) values. Sensitivity and specificity were consistent (63.25% and 74.07%, respectively) between cross-tabulation and discrepant analysis. In addition, the study faced limitations due to its demographic skew (96/147, 65.3% female, well-educated participants), the absence of a comprehensive gold standard for MCI diagnosis, and financial constraints limiting the inclusion of confirmatory neuropsychological testing. CONCLUSIONS The SCREEN, in its current form, does not meet the necessary criteria for an optimal MCI screening tool in primary care settings, primarily due to its longer administration time and lower reliability. As the number of digital health technologies increases and evolves, further testing and refinement of tools such as the SCREEN are essential to ensure their efficacy and reliability in real-world clinical settings. This study advocates for continued research in this rapidly advancing field to better serve the aging population. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/25520.
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Affiliation(s)
- Josephine McMurray
- Lazaridis School of Business & Economics, Wilfrid Laurier University, Brantford, ON, Canada
- Health Studies, Faculty of Human and Social Sciences, Wilfrid Laurier University, Brantford, ON, Canada
| | - AnneMarie Levy
- Lazaridis School of Business & Economics, Wilfrid Laurier University, Brantford, ON, Canada
| | - Wei Pang
- Lazaridis School of Business & Economics, Wilfrid Laurier University, Brantford, ON, Canada
- Biomedical Informatics & Data Science, Yale University, New Haven, CT, United States
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Jun H, Liu Y, Chen E, Becker A, Mattke S. State Department of Motor Vehicles Reporting Mandates of Dementia Diagnoses and Dementia Underdiagnosis. JAMA Netw Open 2024; 7:e248889. [PMID: 38662368 PMCID: PMC11046347 DOI: 10.1001/jamanetworkopen.2024.8889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 02/22/2024] [Indexed: 04/26/2024] Open
Abstract
Importance With older drivers representing the fastest growing segment of the driver population and dementia prevalence increasing with age, policymakers face the challenge of balancing road safety and mobility of older adults. In states that require reporting a dementia diagnosis to the Department of Motor Vehicles (DMV), individuals with dementia may be reluctant to disclose symptoms of cognitive decline, and clinicians may be reluctant to probe for those symptoms, which may be associated with missed or delayed diagnoses. Objective To assess whether DMV reporting policies for drivers with dementia are associated with primary care clinicians' underdiagnosing dementia. Design, Setting, and Participants This cross-sectional study used data from the 100% Medicare fee-for-service program and the Medicare Advantage plans from 2017 to 2019 on 223 036 primary care clinicians with at least 25 Medicare patients. Statistical analysis was performed from July to October 2023. Exposures State DMV reporting policies for drivers with dementia. Main Outcomes and Measures The main outcome was a binary variable indicating whether the clinician underdiagnosed dementia or not. Each clinician's expected number of dementia cases was estimated using a predictive model based on patient characteristics. Comparing the estimation with observed dementia diagnoses identified clinicians who underdiagnosed dementia vs those who did not, after accounting for sampling errors. Results Four states have clinician reporting mandates, 14 have mandates requiring drivers to self-report dementia diagnoses, and 32 states and the District of Columbia do not have explicit requirements. Among primary care clinicians in states with clinician reporting mandates (n = 35 620), 51.4% were female, 91.9% worked in a metropolitan area, and 19.9% of the patient panel were beneficiaries dually eligible for Medicare and Medicaid. Among primary care clinicians in states with patient self-reporting mandates (n = 57 548), 55.7% were female, 83.1% worked in a metropolitan area, and 15.4% of the patient panel were dually eligible for Medicare and Medicaid. Among clinicians in states without mandates, 55.7% were female, 83.0% worked in a metropolitan area, and 14.6% of the patient panel were dually eligible for Medicare and Medicaid. Clinicians in states with clinician reporting mandates had an adjusted 12.4% (95% CI, 10.5%-14.2%) probability of underdiagnosing dementia compared with 7.8% (95% CI, 6.9%-8.7%) in states with self-reporting and 7.7% (95% CI, 6.9%-8.4%) in states with no mandates, an approximately 4-percentage point difference (P < .001). Conclusions and Relevance Results of this cross-sectional study of primary care clinicians suggest that mandatory DMV policies for clinicians to report patients with dementia may be associated with a higher risk of missed or delayed dementia diagnoses. Future research is needed to better understand the unintended consequences and the risk-benefit tradeoffs of these policies.
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Affiliation(s)
- Hankyung Jun
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ying Liu
- The USC Brain Health Observatory, University of Southern California, Los Angeles
| | - Emily Chen
- The USC Brain Health Observatory, University of Southern California, Los Angeles
| | - Andrew Becker
- The USC Brain Health Observatory, University of Southern California, Los Angeles
| | - Soeren Mattke
- The USC Brain Health Observatory, University of Southern California, Los Angeles
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Giacona JM, Bates BM, Sundaram V, Brinker S, Moss E, Paspula R, Kassa S, Zhang R, Ahn C, Zhang S, Basit M, Burkhalter L, Cullum CM, Carlew A, Kelley BJ, Plassman BL, Vazquez M, Vongpatanasin W. Preventing cognitive decline by reducing BP target (PCOT): A randomized, pragmatic, multi-health systems clinical trial. Contemp Clin Trials 2024; 138:107443. [PMID: 38219797 DOI: 10.1016/j.cct.2024.107443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND Growing evidence suggests that intensive lowering of systolic blood pressure (BP) may prevent mild cognitive impairment (MCI) and dementia. However, current guidelines provide inconsistent recommendations regarding optimal BP targets, citing safety concerns of excessive BP lowering in the diverse population of older adults. We are conducting a pragmatic trial to determine if an implementation strategy to reduce systolic BP to <130 and diastolic BP to <80 mmHg will safely slow cognitive decline in older adults with hypertension when compared to patients receiving usual care. METHODS The Preventing Cognitive Decline by Reducing BP Target Trial (PCOT) is an embedded randomized pragmatic clinical trial in 4000 patients from two diverse health-systems who are age ≥ 70 years with BP >130/80 mmHg. Participants are randomized to the intervention arm or usual care using a permuted block randomization within each health system. The intervention is a combination of team-based care with clinical decision support to lower home BP to <130/80 mmHg. The primary outcome is cognitive decline as determined by the change in the modified Telephone Interview for Cognitive Status (TICS-m) scores from baseline. As a secondary outcome, patients who decline ≥3 points on the TICS-m will complete additional cognitive assessments and this information will be reviewed by an expert panel to determine if they meet criteria for MCI or dementia. CONCLUSION The PCOT trial will address the effectiveness and safety of hypertension treatment in two large health systems to lower BP targets to reduce risk of cognitive decline in real-world settings.
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Affiliation(s)
- John M Giacona
- Hypertension Section, Department of Internal Medicine, University of Texas Southwestern Medical Center, USA; Department of Applied Clinical Research, School of Health Professions, University of Texas Southwestern Medical Center, USA
| | - Brooke M Bates
- Hypertension Section, Department of Internal Medicine, University of Texas Southwestern Medical Center, USA; Cardiology Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, USA
| | | | - Stephanie Brinker
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, USA
| | - Elizabeth Moss
- Ambulatory Clinical Pharmacy Services, Parkland Health & Hospital System, USA
| | - Raja Paspula
- Geriatrics and Senior Care Center, Parkland Health & Hospital System, USA
| | - Sentayehu Kassa
- Vickery Health Center, Parkland Health & Hospital System, USA
| | - Rong Zhang
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, USA; Department of Neurology, UT Southwestern Medical Center, USA
| | - Chul Ahn
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, USA
| | - Song Zhang
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, USA
| | - Mujeeb Basit
- Cardiology Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, USA
| | - Lorrie Burkhalter
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, USA
| | - C Munro Cullum
- Department of Neurology, UT Southwestern Medical Center, USA; Psychology Division, Department of Psychiatry, University of Texas Southwestern Medical Center, USA
| | - Anne Carlew
- Psychology Division, Department of Psychiatry, University of Texas Southwestern Medical Center, USA
| | | | - Brenda L Plassman
- Behavioral Medicine & Neurosciences Division, Department of Psychiatry, Duke University School of Medicine, USA
| | - Miguel Vazquez
- Nephrology Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, USA.
| | - Wanpen Vongpatanasin
- Hypertension Section, Department of Internal Medicine, University of Texas Southwestern Medical Center, USA; Cardiology Division, Department of Internal Medicine, University of Texas Southwestern Medical Center, USA.
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Mattke S, Jun H, Chu S, Hanson M. Disparities in Access to Diagnostic Evaluation for Alzheimer's Disease in Individuals Dually Eligible for Medicare and Medicaid: A Modeling Study. J Alzheimers Dis 2024; 98:1403-1414. [PMID: 38517787 DOI: 10.3233/jad-231134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
Background Individuals dually eligible for Medicare and Medicaid (duals) may face greater obstacles to access to disease-modifying Alzheimer's treatments in spite of their higher disease burden, because of clinicians' reluctance to accept Medicaid and the so-called "lesser of" policy, under which Medicaid may pay providers lower rates. Objective To project differential wait times for duals compared to Medicare-only beneficiaries by state. Methods We used State Medicaid payment policy and Medicare enrollment data and a Markov model to predict differential wait times for duals and non-duals from 2023 to 2050. We estimated available diagnostic appointments by state for both groups based on reluctance of clinicians to accept Medicaid and the "lesser of" policy for each year. Results We estimate overall average wait times of almost two years (22.9 months) but almost three times as long for duals (59.8 months) than non-duals (20.7 months) because of higher disease burden. The effects of Medicaid payment policy would increase average wait times for duals to 89 months with 20 states having wait times of 99 months or more, which would effectively deprive duals of access. Conclusions The added average wait times in many states would effectively deprive duals from access to treatment and translate into avoidable disease progression and mortality. Policy interventions to reduce financial and nonfinancial obstacles are dearly needed to avoid deepening disparities. Examples are coverage arrangements that integrate Medicare and Medicaid coverage, covering the co-payment for physician services in full, and stricter network adequacy requirements for Medicaid Managed Care plans.
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Affiliation(s)
- Soeren Mattke
- The USC Brain Health Observatory, University of Southern California, Los Angeles, CA, USA
| | - Hankyung Jun
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | | | - Mark Hanson
- The USC Brain Health Observatory, University of Southern California, Los Angeles, CA, USA
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Liu Y, Jun H, Becker A, Wallick C, Mattke S. Detection Rates of Mild Cognitive Impairment in Primary Care for the United States Medicare Population. J Prev Alzheimers Dis 2024; 11:7-12. [PMID: 38230712 PMCID: PMC10995024 DOI: 10.14283/jpad.2023.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/17/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Existing evidence points to substantial gaps in detecting mild cognitive impairment in primary care but is based on limited or self-reported data. The recent emergence of disease-modifying treatments for the Alzheimer's disease, the most common etiology of mild cognitive impairment, calls for a systematic assessment of detection rates in primary care. OBJECTIVES The current study aims to examine detection rates for mild cognitive impairment among primary care clinicians and practices in the United States using Medicare claims and encounter data. DESIGN Observational study. SETTING Medicare administrative data. PARTICIPANTS The study sample includes a total of 226,756 primary care clinicians and 54,597 practices that had at least 25 patients aged 65 or older, who were enrolled in Medicare fee-for-service or a Medicare Advantage plan between 2017 and 2019. MEASUREMENTS The detection rate for mild cognitive impairment is assessed as the ratio between the observed diagnosis rate of a clinician or practice as documented in the data, and the expected rate based on a predictive model. RESULTS The average detection rates for mild cognitive impairment is 0.08 (interquartile range=0.00-0.02) for both clinicians and practices, suggesting that only about 8% of expected cases were diagnosed on average. Only 0.1% of clinicians and practices had diagnosis rates within the expected range. CONCLUSIONS Mild cognitive impairment is vastly underdiagnosed, pointing to an urgent need to improve early detection in primary care.
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Affiliation(s)
- Y Liu
- Ying Liu, PhD, Center for Economic and Social Research, University of Southern California, 635 Downey Way, Los Angeles, CA 90089, USA,
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Frederiksen KS, Morató X, Zetterberg H, Gauthier S, Boada M, Pytel V, Mattke S. Focusing on Earlier Management of Alzheimer Disease: Expert Opinion Based on a Modified Nominal Group Technique. Alzheimer Dis Assoc Disord 2024; 38:1-7. [PMID: 38300883 DOI: 10.1097/wad.0000000000000600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/16/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Despite the number of people living with Alzheimer disease (AD), awareness of the early stages of this condition, including mild cognitive impairment due to AD-which poses management challenges-continues to be low. To identify areas for improvement in early AD management, dementia specialists convened in a virtual roundtable meeting. METHODOLOGY A modified version of the nominal group technique was followed to prioritize specific topics and allow experts to provide their opinions. The overarching topics prioritized and discussed were (1) education and support for primary care physicians on cognitive assessment, detection of mild cognitive impairment, and patient monitoring; (2) nonpharmacological interventions; (3) and the introduction of disease-modifying therapies. CONCLUSIONS Consensus was achieved regarding the need for educating primary care physicians on identifying people with cognitive impairment and for better diagnostic tools for its detection and early management. Management of mild cognitive impairment due to AD should encompass an adequate follow-up schedule aiming to maintain function for as long as possible, and primary care physicians and patients should be aware of the benefits of nonpharmacological interventions.
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Affiliation(s)
- Kristian Steen Frederiksen
- Danish Dementia Research Centre, Department of Neurology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Xavier Morató
- Ace Alzheimer Center Barcelona, Spain
- Universitat International de Catalunya-Barcelona, Spain
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, University College London Institute of Neurology, London, UK
- UK Dementia Research Institute at University College London, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong
- Wisconsin Alzheimer's Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Serge Gauthier
- AD and Related Disorders Research Unit, McGill Center for Studies in Aging, Verdun, Quebec, Canada
- Departments of Neurology & Neurosurgery, Psychiatry, and Medicine at McGill, Montréal (Québec), Canada
| | - Mercè Boada
- Ace Alzheimer Center Barcelona, Spain
- Universitat International de Catalunya-Barcelona, Spain
- Research Center on Neurodegenerative Diseases (CIBERNED), Instituto de Salud Carlos III, Madrid, Spain
| | - Vanesa Pytel
- Ace Alzheimer Center Barcelona, Spain
- Universitat International de Catalunya-Barcelona, Spain
| | - Soeren Mattke
- Center for Improving Chronic Illness Care at the University of Southern California, San Diego, CA
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Chung SC, Rossor M, Torralbo A, Ytsma C, Fitzpatrick NK, Denaxas S, Providencia R. Cognitive Impairment and Dementia in Atrial Fibrillation: A Population Study of 4.3 Million Individuals. JACC. ADVANCES 2023; 2:100655. [PMID: 38938718 PMCID: PMC11198352 DOI: 10.1016/j.jacadv.2023.100655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
| | | | | | | | | | | | - Rui Providencia
- Institute of Health informatics Research, University College London, 222 Euston Road, NW1 2DA London, United Kingdom.
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Hsu JH, Liu CC, Chen IW, Wu JY, Huang PY, Liu TH, Hung KC. Efficacy of the visual cognitive assessment test for mild cognitive impairment/mild dementia diagnosis: a meta-analysis. Front Public Health 2023; 11:1293710. [PMID: 38026272 PMCID: PMC10644725 DOI: 10.3389/fpubh.2023.1293710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Mild cognitive impairment (MCI) is an intermediate stage between normal ageing and dementia. The early identification of MCI is important for timely intervention. The visual cognitive assessment test (VCAT) is a brief language-neutral screening tool for detecting MCI/mild dementia. This meta-analysis evaluated the diagnostic efficacy of the VCAT for MCI/mild dementia. Methods Medline, Embase, Google Scholar, and Cochrane Library were searched from their inception until August 2023 to identify studies using VCAT to diagnose MCI/mild dementia. The primary outcome was to assess the diagnostic accuracy of the VCAT for detecting MCI/mild dementia through area under the receiver operating characteristic curve (AU-ROC) analysis. The secondary outcome was to explore the correlation between VCAT scores and MCI/mild dementia presence by comparing scores among patients with and without MCI/mild dementia. Pooled sensitivity, specificity, and area under the curve (AUC) were calculated. Results Five studies with 1,446 older adults (mean age 64-68.3 years) were included. The percentage of participants with MCI/mild dementia versus controls ranged from 16.5% to 87% across studies. All studies were conducted in Asian populations, mostly Chinese, in Singapore and Malaysia. The pooled sensitivity was 80% [95% confidence interval (CI) 68%-88%] and the specificity was 75% (95% CI 68%-80%). The AU-ROCC was 0.77 (95% CI 0.73-0.81). Patients with MCI/mild dementia had lower VCAT scores than the controls (mean difference -6.85 points, p < 0.00001). Conclusion VCAT demonstrated acceptable diagnostic accuracy in distinguishing MCI/mild dementia in cognitively normal older adults. As a language-neutral and culturally unbiased tool, the VCAT shows promise in detecting MCI/mild dementia. Further studies in non-Asian populations are required. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42023453453.
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Affiliation(s)
- Jui-Hung Hsu
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
- Department of Nursing, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Jheng-Yan Wu
- Department of Nutrition, Chi Mei Medical Center, Tainan, Taiwan
| | - Po-Yu Huang
- Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Ting-Hui Liu
- Department of Psychiatry, Chi Mei Medical Center, Tainan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
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