Home health and informal care utilization and costs over time in Alzheimer's disease

Costs of Early Stage Alzheimer's Disease in the United States: Cross-Sectional Analysis of a Prospective Cohort Study (GERAS-US)1

BACKGROUND

Costs associated with early stages of Alzheimer's disease (AD; mild cognitive impairment [MCI] and mild dementia [MILD]) are understudied.

OBJECTIVE

To compare costs associated with MCI and MILD due to AD in the United States.

METHODS

Data included baseline patient/study partner medical history, healthcare resource utilization, and outcome assessments as part of a prospective cohort study. Direct, indirect, and total societal costs were derived by applying standardized unit costs to resources for the 1-month pre-baseline period (USD2017). Costs/month for MCI and MILD cohorts were compared using analysis of variance models. To strengthen the confidence of diagnosis, amyloid-β (Aβ) tests were included and analyses were replicated stratifying within each cohort by amyloid status [+ /-].

RESULTS

Patients (N = 1327) with MILD versus MCI had higher total societal costs/month ($4243 versus $2816; p < 0.001). These costs were not significantly different within each severity cohort by amyloid status. The largest fraction of overall costs were informal caregiver costs (45.1%) for the MILD cohort, whereas direct medical patient costs were the largest for the MCI cohort (39.0%). Correspondingly, caregiver time spent on basic activities of daily living (ADLs), instrumental ADLs, and supervision time was twice as high for MILD versus MCI (all p < 0.001).

CONCLUSION

Early AD poses a financial burden, and despite higher functioning among those with MCI, caregivers were significantly impacted. The major cost driver was the patient's clinical cognitive-functional status and not amyloid status. Differences were primarily due to rising need for caregiver support.

Development and Validation of a Prediction Model for 6-Month Societal Costs in Older Community Care-Recipients in Multiple Countries; the IBenC Study

This study aims to develop and validate a prediction model of societal costs during a period of 6-months in older community care-recipients across multiple European countries. Participants were older community care-recipients from 5 European countries. The outcome measure was mean 6-months total societal costs of resource utilisation (healthcare and informal care). Potential predictors included sociodemographic characteristics, functional limitations, clinical conditions, and diseases/disorders. The model was developed by performing Linear Mixed Models with a random intercept for the effect of country and validated by an internal-external validation procedure. Living alone, caregiver distress, (I)ADL impairment, required level of care support, health instability, presence of pain, behavioural problems, urinary incontinence and multimorbidity significantly predicted societal costs during 6 months. The model explained 32% of the variation within societal costs and showed good calibration in Iceland, Finland and Germany. Minor model adaptations improved model performance in The Netherland and Italy. The results can provide a valuable orientation for policymakers to better understand cost development among older community care-recipients. Despite substantial differences of countries’ care systems, a validated cross-national set of key predictors could be identified.

The Effect of the "Great Village" on Psychological Outcomes, Burden, and Mastery in African American Caregivers of Persons Living With Dementia

The "Great Village," a cultural adaptation of a psychoeducation intervention the "Savvy Caregiver" for African American caregivers of persons living with dementia (PLwD), aims to develop caregivers' skills and improve the quality of the lives of both the PLwD and their caregivers. The goal of this study was to determine the effectiveness of the Great Village on depressive symptoms, anxiety, burden, and mastery in African American caregivers (N = 142). A three-arm randomized control trial (Great Village, Great Village + exercise, and attention control) was conducted over a period of 6 months. Caregivers who received either Great Village or Great Village + exercise reported significant reduction in depressive symptoms and improvement in mastery. Caregivers who received only Great Village reported a reduction in anxiety. Receiving no intervention worsened caregiver burden. African American caregivers should receive culturally tailored interventions to support their health and well-being and improve their competence in caregiving.

Informal and formal care among persons with dementia immediately before nursing home admission

Background

Dementia is a care intensive disease, especially in the later stages, implying in many cases a substantial carer burden. This study assesses the use of formal and informal care resources among persons with dementia during the last month before nursing home admission. It also describes main providers of informal care and assesses the extent of informal care rendered by the extended social network.

Methods

In this cross-sectional study, we collected data about persons with dementia that were newly admitted to a nursing home in Norway. Information about the amount of formal and informal care during the last 4 weeks preceding nursing home admission was collected from the primary caregivers. Clinical data were collected by examining the patients, while sociodemographic data was collected from the patients’ files.

Results

A total of 395 persons with dementia were included. The amount of informal care provided by the family caregiver was 141.9 h per month SD = 227.4. Co-resident patients received five times more informal care than non-co-residents. Informal care from the extended social network was provided to 212 patients (53.7%) with a mean of 5.6 (SD = 11.2) hours per month and represented 3.8% of the total informal care rendered to the patients. Formal care was provided to 52.7% of the patients with a mean of 18.0 (SD = 50.1) hours per month. Co-residency was significantly associated with more informal care, and the associations varied with respect to age, relation to the caregiver, and the caregiver’s working situation. Good/excellent general health was associated with less formal care.

Conclusion

Persons with dementia on the verge of admission to a nursing home are mainly supported by the family caregiver, and the use of informal care is particularly high among co-residents. In order to delay nursing home admission, future research should explore the unrealized care potential in extended social networks, as well as the potential for increasing the number of recipients of formal care services.

Reduced Awareness of Memory Deficit is Associated With Increased Medicare Home Health Care Use in Dementia

OBJECTIVE

The objective of this study was to examine whether reduced awareness of memory deficits in individuals with dementia is associated with more frequent need for Medicare home health care services.

METHODS

Cross-sectional analyses were conducted in a multicenter, clinic-based cohort. In total, 192 participants diagnosed with dementia and their informants were independently asked whether or not the participant demonstrated cognitive symptoms of dementia related to memory and word-finding. Participant self-awareness was measured as the discrepancy between participant and caregiver report of these symptoms. Annual Medicare home health benefit use data was obtained from Medicare claims matched by year to the Predictors study visit.

RESULTS

Participants that used home health services had lower awareness scores than those who did not. Awareness remained independently associated with home health use in a logistic regression adjusted for age, gender, education, caregiver relationship, global cognition, dementia subtype, and medical comorbidities.

IMPLICATIONS

Reduced self-awareness of memory deficits in individuals with dementia is associated with more frequent use of Medicare home health services. The disproportionate use of in-home assistance as a function of awareness level may reflect dangers faced by patients, and challenges faced by caregivers, when patients have limited awareness of their memory deficits. Current results have implications for clinical care, caregiver education, and models of health care utilization.

Differences within Differences: Gender Inequalities in Caregiving Intensity Vary by Race and Ethnicity in Informal Caregivers

Among the 50+ million informal caregivers in the US, substantial gender, racial/ethnic, and socioeconomic disparities in caregiving intensity are well-documented. However, those disparities may be more nuanced: gender disparities in caregiving intensity may vary by race/ethnicity (White, Black, and Hispanic) and socioeconomic status (SES). We used data from the 2011 National Study of Caregiving and applied generalized linear models to estimate associations between three measures of caregiver intensity (ADLs, IADLs, and hours caregiving/month) and the three sociodemographic factors with their interaction terms. Black female caregivers provided significantly higher levels of care than White females and males for both IADL caregiving and hours/month spent caregiving. Black caregivers spent an average of 28.5 more hours/month (95%CI 1.7-45.2) caregiving than White caregivers. These findings highlight the need to understand the complex disparities within population subgroups and how intersections between gender, race/ethnicity, and SES can be used to develop effective policies to reduce disparities and improve caregiver quality-of-life.

Predictors of Societal Costs of Older Care-Dependent Adults Living in the Community in 11 European Countries

Background:

The objective was to identify predictors of societal costs covering formal and informal care utilization by older home care clients in 11 European countries.

Methods:

Societal costs of 1907 older clients receiving home care for 12 months from the Aged in Home care (AdHoc) study were estimated using the InterRAI Minimum Data Set for Home Care’s (MDS-HC) resource use items. Predictors (medical, functional, and psychosocial domains) of societal costs were identified by performing univariate and multivariate generalized linear model analyses.

Results:

Mean societal costs per participant were €36 442, ranging from €14 865 in Denmark to €78 836 in the United Kingdom. In the final multivariate model, country, being married, activities of daily living (ADL) dependency, cognitive impairment, limitations of going out, oral conditions, number of medications, arthritis, and cerebro vascular accident (CVA) were significantly associated with societal costs.

Conclusions:

Of the predictors, ADL dependency and limitations of going out may be modifiable. Developing interventions targeted at improving these conditions may create opportunities to curtail societal costs.

Influences on the access to and use of formal community care by people with dementia and their informal caregivers: a scoping review

BACKGROUND

The literature describes the obstacles to sufficient care faced by people with dementia and their informal caregivers. Although factors influencing access and utilisation are frequently studied, the body of knowledge lacks an overview of aspects related to influence. The frequently used Behavioural Model of Health Care Use (BM) could be used to structure and explain these aspects. An adaptation of the BM emphasises psychosocial influences and appears to enrich the understanding of the use of long-term care for dementia.

METHODS

We conducted a scoping review with the aim of providing an overview of the aspects influencing the access to and utilisation of formal community care in dementia. Our search covered the PubMed, CINAHL, Social Science Citation Index and PsychInfo databases, as well as grey literature. Two researchers assessed the full texts for eligibility. A data extraction form was developed and tested. We analysed the main topics investigated by the studies and mapped and described the investigated psychosocial aspects according to the BM after narratively summarising the findings. We used the Mixed Method Appraisal Tool (MMAT) to critically appraise the included studies.

RESULTS

A total of 94 studies were included: n = 55 with quantitative designs, 35 with qualitative designs and four with mixed methods. The studies investigated different services, mainly focusing on health care services. One third of the studies provided information regarding the severity of dementia. The most frequently investigated main topics were ethnicity and attitudes towards services. Psychosocial aspects were frequently investigated, although few studies considered the perspectives of people with dementia. Approximately half of the studies reported a theoretical framework. The adapted BM facilitated the structuring and description of psychosocial aspects. However, this instrument did not address topics beyond the scope of psychosocial aspects, such as sociodemographic characteristics.

CONCLUSIONS

The access to and utilisation of formal community care for dementia can only be partly explained by individual influencing aspects. Therefore, a theoretical framework would likely help to describe this complex subject. Our findings indicate that the psychosocial categories of the adapted BM enriched the original BM, and that people with dementia should more often be included in healthcare service research to ensure a better understanding of the barriers to accessing formal community care.

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

Approximately 34 million family and friends provided unpaid care to individuals aged 50 and older in 2015. It is difficult to place a value on that time, because no payment is made to the caregiver, and multiplying caregiving hours by a wage does not account for the value of lost leisure time, implications for future employability and wages, or any intrinsic benefits accrued to the care provider. This study used a dynamic discrete choice model to estimate the costs of informal care provided by a daughter to her mother, including these other costs and benefits not typically accounted for, and compared these cost estimates for 4 categories of the mother's functional status: doctor-diagnosed memory-related disease, limitations in activities of daily living (ADLs), combination of both, cannot be left alone for 1 hour or more. We studied women aged 40 to 70 with a living mother at the start of the sample period (N=3,427 adult daughters) using data from the Health and Retirement Study (1998-2012). The primary outcome was the monetized change in well-being due to caregiving, what economists call "welfare costs." We estimate that the median cost to the daughter's well-being of providing care to an elderly mother ranged from $144,302 to $201,896 over 2 years, depending on the mother's functional status. These estimates suggest that informal care cost $277 billion in 2011, 20% more than estimates that account only for current foregone wages.

The Economic Value of Informal Caregiving for Persons With Dementia: Results From 38 States, the District of Columbia, and Puerto Rico, 2015 and 2016 BRFSS

OBJECTIVES

To estimate the economic value from a societal perspective of informal caregiving of persons with dementia in 38 states, the District of Columbia, and Puerto Rico.

METHODS

Using a cost replacement method and data from the 2015 and 2016 Behavioral Risk Factor Surveillance System caregiver module, the US Bureau of Labor Statistics May 2016 Occupation Profiles, and the US Department of Labor, we estimated the number and economic direct cost of caregiving hours.

RESULTS

An estimated 3.2 million dementia caregivers provided more than 4.1 billion hours of care, with an average of 1278 hours per caregiver. The median hourly value of dementia caregiving was $10.28. Overall, we valued these caregiving hours at $41.5 billion, with an average of $13 069 per caregiver.

CONCLUSIONS

Caregivers of persons with dementia provide care that has important economic implications. Without these efforts, many people would either not receive needed care or have to pay for that support. Surveillance data can be used to estimate the contributions of informal caregivers and the economic value of the care they provide.

Effects of Cognition, Function, and Behavioral and Psychological Symptoms on Medicare Expenditures and Health Care Utilization for Persons With Dementia

Background

Clinical features of dementia (cognition, function, and behavioral/psychological symptoms [BPSD]) may differentially affect Medicare expenditures/health care utilization.

Methods

We linked cross-sectional data from the Aging, Demographics, and Memory Study to Medicare data to evaluate the association between dementia clinical features among those with dementia and Medicare expenditures/health care utilization (n = 234). Cognition was evaluated using the Mini-Mental State Examination (MMSE). Function was evaluated as the number of functional limitations (0-10). BPSD was evaluated as the number of symptoms (0-12). Expenditures were estimated with a generalized linear model (log-link and gamma distribution). Number of hospitalizations, institutional outpatient visits, and physician visits were estimated with a negative binomial regression. Medicare covered skilled nursing days were estimated with a zero-inflated negative binomial model.

Results

Cognition and BPSD were not associated with expenditures. Among individuals with less than seven functional limitations, one additional limitation was associated with $123 (95% confidence interval: $19-$227) additional monthly Medicare spending. Better cognition and poorer function were associated with more hospitalizations among those with an MMSE less than three and less than six functional limitations, respectively. BPSD had no effect on hospitalizations. Poorer function and fewer BPSD were associated with more skilled nursing among individuals with one to seven functional limitations and more than four symptoms, respectively. Cognition had no effect on skilled nursing care. No clinical feature was associated with institutional outpatient care. Of individuals with an MMSE less than 15, poorer cognition was associated with fewer physician visits. Among those with more than six functional limitations, poorer function was associated with fewer physician visits.

Conclusions

Poorer function, not cognition or BPSD, was associated with higher Medicare expenditures.

Effects of cognition, function, and behavioral and psychological symptoms on out-of-pocket medical and nursing home expenditures and time spent caregiving for persons with dementia

INTRODUCTION

Clinical features of dementia (cognition, function, and behavioral and psychological symptoms) may differentially affect out-of-pocket medical and nursing home (NH) expenditures and informal care received (outcomes).

METHODS

We used cross-sectional data (Aging, Demographics, and Memory Study) to estimate probabilities of experiencing outcomes by clinical features. For those experiencing an outcome, we estimated effects of clinical features on the amount of the outcome.

RESULTS

No clinical feature predicted the probability of having out-of-pocket medical expenditures. For those with medical expenditures, higher cognition and poorer function were associated with more spending. Poorer function predicted having out-of-pocket NH expenditures. For those with NH expenditures, no clinical feature predicted the amount. Poorer function and a greater number of behavioral and psychological symptoms predicted the probability of receiving caregiving. For those receiving care, poorer function was associated with more caregiving.

CONCLUSIONS

Clinical features differentially impact outcomes with poorer function associated with all types of costs and caregiving received.

Determinants of formal care use and expenses among in-home elderly in Jing'an district, Shanghai, China

The need for formal care among the elderly population has been increasing due to their greater longevity and the evolution of family structure. We examined the determinants of the use and expenses of formal care among in-home elderly adults in Shanghai. A two-part model based on the data from the Shanghai Long-Term Care Needs Assessment Questionnaire was applied. A total of 8428 participants responded in 2014 and 7100 were followed up in 2015. The determinants of the probability of using formal care were analyzed in the first part of the model and the determinants of formal care expenses were analyzed in the second part. Demographic indicators, living arrangements, physical health status, and care type in 2014 were selected as independent variables. We found that individuals of older age; women; those with higher Activities of Daily Living (ADL) scores; those without spouse; those with higher income; those suffering from stroke, dementia, lower limb fracture, or advanced tumor; and those with previous experience of formal and informal care were more likely to receive formal care in 2015. Furthermore, age, income and formal care fee in 2014 were significant predictors of formal care expenses in 2015. Taken together, the results showed that formal care provision in Shanghai was not determined by ADL scores, but was instead more related to income. This implied an inappropriate distribution of formal care among elderly population in Shanghai. Additionally, it appeared difficult for the elderly to quit the formal care once they begun to use it. These results highlighted the importance of assessing the need for formal care, and suggested that the government offer guidance on formal care use for the elderly.

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.

The Predictors study: Development and baseline characteristics of the Predictors 3 cohort

INTRODUCTION

The Predictors study was designed to predict the length of time to major disease outcomes in Alzheimer's disease (AD) patients. Here, we describe the development of a new, Predictors 3, cohort.

METHODS

Patients with prevalent or incident AD and individuals at-risk for developing AD were selected from the North Manhattan community and followed annually with instruments comparable to those used in the original two Predictors cohorts.

RESULTS

The original Predictors cohorts were clinic based and racially/ethnically homogenous (94% white, 6% black; 3% Hispanic). In contrast, the 274 elders in this cohort are community-based and ethnically diverse (39% white, 40% black, 21% other; 78% Hispanic). Confirming previous observations, psychotic features were associated with poorer function and mental status and extrapyramidal signs with poorer function.

DISCUSSION

This new cohort will allow us to test observations made in our original clinic-based cohorts in patients that may be more representative of the general community.

A Longitudinal Study of Transitions Between Informal and Formal Care in Alzheimer Disease Using Multistate Models in the European ICTUS Cohort

BACKGROUND

We aimed to describe longitudinal patterns of care in community-dwelling European patients with Alzheimer disease (AD), and determine patient-, caregiver-, and country-related predictors of transitions across different care levels.

METHODS

Two-year follow-up data from ICTUS cohort (1375 patients with AD, 12 countries) were analyzed using multistate Markov models to describe transitions across states of care and identify their predictors.

RESULTS

Of the patients, 61.3% stayed in the same state during follow-up, and only 9.5% experienced ≥2 changes between states. Six-month transition probabilities were 11% for informal to formal care and 13% for formal to informal care (in the community). Older age, male gender, poorer cognitive and behavioral scores, and country of residence were associated with transitioning from informal to formal care, but only country of residence was associated with the reverse transition.

DISCUSSION

Changes between different types of care were rare during follow-up, and country factors in particular influenced these transitions.

Longitudinal Associations between Survival in Alzheimer's Disease and Cholinesterase Inhibitor Use, Progression, and Community-Based Services

BACKGROUND/AIMS

Factors including rate of disease progression, different aspects of cholinesterase inhibitor (ChEI) treatment, and use of community-based services might affect the longitudinal outcome of Alzheimer's disease (AD). Whether these factors alter life expectancy in AD is unclear. We therefore examined the association between long-term ChEI therapy and survival.

METHODS

The present study included 1,021 patients with a clinical diagnosis of AD and a Mini-Mental State Examination score of 10-26 at baseline from a 3-year, prospective, multicenter study of ChEI therapy in clinical practice. The relationship of potential predictors with mortality was analyzed using Cox regression models.

RESULTS

After up to 16 years of follow-up, 841 (82%) of the participants had died. In the Alzheimer's Disease Assessment Scale-cognitive subscale, a mean decline of ≥ 4 points/year or ≥ 2 points/year on the Physical Self-Maintenance Scale was a risk factor for an earlier death. In the multivariate models, longer survival was associated with higher ChEI dose and longer duration of treatment. Users of community-based services at baseline exhibited a 1-year shorter mean life expectancy than nonusers.

CONCLUSION

A longer survival time can be anticipated for AD patients with slower deterioration who receive and tolerate higher ChEI doses and a longer duration of treatment.

Methodological challenges in assessing the impact of comorbidities on costs in Alzheimer's disease clinical trials

BACKGROUND

Alzheimer's disease (AD) is associated with considerable costs and has a significant impact on health and social care systems.

OBJECTIVE

This study assessed whether baseline comorbidities present in 2,594 patients with AD participating in two semagacestat randomized placebo-controlled trials (RCTs) would significantly impact overall costs.

METHODS

Resource utilization was captured using the Resource Utilization in Dementia Scale-Lite. Comorbidities and concomitant medications were tabulated via patient and caregiver reports. Only baseline data were analyzed. Direct and indirect costs per month were calculated per patient. The relationship between cost and explanatory variables was explored in a regression model.

RESULTS

The baseline monthly cost of care in this RCT population was £1,147 ± 2,483, with informal care costs accounting for 75% of costs. Gender, age, and functional status were significant predictors of costs (p ≤ 0.0001). The cost ratio was not impacted when the number of comorbidities was added to the model (cost ratio = 0.95; 95% CI 0.91-0.99) or when combined with the number of concomitant medications (cost ratio = 0.97; 95% CI 0.95-1.00). Inconsistent findings related to the impact of individual comorbidities on costs were noted in sensitivity analyses.

CONCLUSIONS

The number of comorbidities, alone or when combined with concomitant medications, did not impact baseline costs of care, perhaps because RCTs often enroll less severely ill and more medically stable patients. However, higher costs were consistently associated with greater functional impairment similar to non-RCT databases. Supplemental sources (e.g., claims databases) are likely needed to better estimate the effects of disease and treatment on costs of illness captured in RCTs for AD.

Economic valuation and determinants of informal care to people with Alzheimer's disease

OBJECTIVE

To estimate the monetary value of informal care to people with Alzheimer's disease (AD) in Spain and to identify the main determinants of the time of informal care.

DATA AND METHODS

We used the Survey on Disabilities, Autonomy and Dependency carried out in Spain in 2008 to obtain information on disabled individuals with Alzheimer and their informal caregivers. Assessment of informal care time was performed using three different approaches: the proxy good method, the opportunity cost method and the contingent valuation method. A statistical multivariate analysis--an ordered probit model--was performed to study the determinants of informal care provided.

RESULTS

The average number of required informal hours per year was 4,151. The cost per caregiver ranged from 31,839 to 52,760 euros under the proxy good method; it was estimated at 20,053 euros under the opportunity cost method; and it ranged between 18,680 and 29,057 euros under the contingent valuation method. The degree of dependency and the formal care services were the main variables that explained the variability of the informal time provided. When a person presents a very high level of dependency, the probability of receiving more than 100 h of informal care per week is 25.8% higher than a non-dependent person with AD. Formal in-home care complements informal caregiving, while formal care outside the home replaces it.

CONCLUSIONS

Informal care represents a high social cost in people with AD, regardless of the estimation method considered. A higher level of dependence is associated with more hours of informal care provided.

Cost-of-illness study in a retrospective cohort of patients with dementia in Lima, Peru

Dementia is a major cause of dependency and disability among older persons, and imposes huge economic burdens. Only a few cost-of-illness studies for dementia have been carried out in middle and low-income countries.

Rural-urban differences in the long-term care of the disabled elderly in China

Background

In China, the rapid rate of population aging and changes in the prevalence of disability among elderly people could have significant effects on the demand for long-term care. This study aims to describe the urban-rural differences in use and cost of long-term care of the disabled elderly and to explore potential influencing factors.

Methods

This study uses data from a cross-sectional survey and a qualitative investigation conducted in Zhejiang province in 2012. The participants were 826 individuals over 60 years of age, who had been bedridden or suffered from dementia for more than 6 months. A generalized linear model and two-part regression model were applied to estimate costs, with adjustment of covariates.

Results

Pensions provide the main source of income for urban elderly, while the principal income source for rural elderly is their family. Urban residents spend more on all services than do rural residents. Those who are married spend less on daily supplies and formal care than the unmarried do. Age, incapacitation time, comorbidity number, level of income, and bedridden status influence spending on medical care (β=-0.0316, -0.0206, 0.1882, 0.3444, and -0.4281, respectively), but the cost does not increase as the elderly grow older. Urban residents, the married, and those with a higher income level tend to spend more on medical equipment. Urban residence and living status are the two significant factors that affect spending on personal hygiene products.

Conclusions

The use of long-term care services varies by living area. Long-term care of the disabled elderly imposes a substantial burden on families. Our study revealed that informal care involves huge opportunity costs to the caregivers. Chinese policy makers need to promote community care and long-term care insurance to relieve the burden of families of disabled elderly, and particular attention should be given to the rural elderly.

The worldwide economic impact of dementia 2010

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring the relationship between Alzheimer's disease severity and longitudinal costs

OBJECTIVE

The joint impact of cognitive, functional, and behavioral statuses must be measured when exploring the impact of new drugs on Alzheimer's disease (AD) costs. There are very few recent studies of AD costs by all dimensions of disease severity. Our objective was to improve estimation of the relationship between AD severity and costs of AD care by using more comprehensive AD data severity and a large sample size.

METHODS

Participants were community-dwelling AD patients recruited between 2003 and 2005 and followed annually during a 2-year period in 50 French memory clinics. We used the Resource Use in Dementia questionnaire to estimate costs from a societal perspective. We explored the presence of potential endogeneity bias by using instrumental variable regressions.

RESULTS

Cognitive declines impacted informal costs more than medical and nonmedical costs, while functional declines impacted nonmedical costs more than medical and informal costs. Both cognitive and function declines increased the total costs of care. We found that the endogeneity of these variables led to a large underestimation of their impact of AD severity on costs.

CONCLUSION

Potential endogeneity should be controlled for to prevent biased estimations of the impact of AD severity measures on costs.

Road to the nursing home: costs and disease progression among medicare beneficiaries with ADRD

OBJECTIVES

To estimate long-term care costs and disease progression among Medicare beneficiaries aged 65+ with ADRD.

METHODS

Retrospective analysis of Medicare Part A claims and nursing home (NH) Minimum Data Set (MDS) records among beneficiaries 1999-2007. Expenditures were grouped into 3 periods; PRE, events occurring between date of ADRD diagnosis, before first NH admission; PERI, from first NH admission to at least 100 days; and, PERM, after 120 days. Utilization and reimbursements were computed for each period.

RESULTS

Demographics of the3,681,702 ADRD beneficiaries showed average age of 83 (+/-7), female (67.7%) and white (87.4%). Medicare reimbursements per person increased by 58% from the PRE ($47,912) to PERM period ($75,654). Age, ethnicity, gender (male), and comorbidities were significantly related to total reimbursements in each phase.

CONCLUSIONS

Applying a taxonomy of NH phases, Medicare expenditures per person year are higher among patients in their terminal phase and higher still with comorbidities.

The relationship between formal and informal care among adult Medicaid Personal Care Services recipients

OBJECTIVES

To test hypotheses concerning the relationship between formal and informal care and to estimate the impact of hours of formal care authorized for Medicaid Personal Care Services (PCS) on the utilization of informal care.

DATA SOURCES/STUDY SETTING

Data included home care use and adult Medicaid beneficiary characteristics from assessments of PCS need in four Medicaid administrative areas in Texas.

STUDY DESIGN

Cross-sectional design using ordinary least-squares (OLS) and instrumental variable (IV) methods.

DATA COLLECTION/EXTRACTION METHODS

The study database consisted of assessment data on 471 adults receiving Medicaid PCS from 2004 to 2006.

PRINCIPAL FINDINGS

Both OLS and IV estimates of the impact of formal care on informal care indicated no statistically significant relationship. The impact of formal care authorized on informal care utilization was less important than the influence of beneficiary need and caregiver availability. Living with a potential informal caregiver dramatically increased the hours of informal care utilized by Medicaid PCS beneficiaries.

CONCLUSIONS

More formal home care hours were not associated with fewer informal home care hours. These results imply that policies that decrease the availability of formal home care for Medicaid PCS beneficiaries will not be offset by an increase in the provision of informal care and may result in unmet care needs.

Dementia home care resources: how are we managing?

With the number of people living with dementia expected to more than double within the next 25 years, the demand for dementia home care services will increase. In this critical ethnographic study, we drew upon interview and participant data with persons with dementia, family caregivers, in-home providers, and case managers in nine dementia care networks to examine the management of dementia home care resources. Three interrelated, dialectical themes were identified: (1) finite formal care-inexhaustible familial care, (2) accessible resources rhetoric-Iinaccessible resources reality, and (3) diminishing care resources-increasing care needs. The development of policies and practices that provide available, accessible, and appropriate resources, ensuring equitable, not necessarily equal, distribution of dementia care resources is required if we are to meet the goal of aging in place now and in the future.

A randomized, double-blind, placebo-controlled trial of simvastatin to treat Alzheimer disease

BACKGROUND

Lowering cholesterol is associated with reduced CNS amyloid deposition and increased dietary cholesterol increases amyloid accumulation in animal studies. Epidemiologic data suggest that use of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) may decrease the risk of Alzheimer disease (AD) and a single-site trial suggested possible benefit in cognition with statin treatment in AD, supporting the hypothesis that statin therapy is useful in the treatment of AD.

OBJECTIVE

To determine if the lipid-lowering agent simvastatin slows the progression of symptoms in AD.

METHODS

This randomized, double-blind, placebo-controlled trial of simvastatin was conducted in individuals with mild to moderate AD and normal lipid levels. Participants were randomly assigned to receive simvastatin, 20 mg/day, for 6 weeks then 40 mg per day for the remainder of 18 months or identical placebo. The primary outcome was the rate of change in the Alzheimer's Disease Assessment Scale-cognitive portion (ADAS-Cog). Secondary outcomes measured clinical global change, cognition, function, and behavior.

RESULTS

A total of 406 individuals were randomized: 204 to simvastatin and 202 to placebo. Simvastatin lowered lipid levels but had no effect on change in ADAS-Cog score or the secondary outcome measures. There was no evidence of increased adverse events with simvastatin treatment.

CONCLUSION

Simvastatin had no benefit on the progression of symptoms in individuals with mild to moderate AD despite significant lowering of cholesterol.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that simvastatin 40 mg/day does not slow decline on the ADAS-Cog.

A review of the methods used to estimate the cost of Alzheimer's disease in the United States

BACKGROUN/RATIONALE: To determine the suitability of published estimates of the US cost of Alzheimer's disease (AD) for use in cost-effectiveness models for new AD treatments.

METHODS

A systematic literature review of published information on direct medical, direct nonmedical, indirect, and informal care costs for different levels of disease severity.

RESULTS

Nineteen studies were included in the review. In studies presenting mean costs by disease severity, the change in different types of costs with increasing disease severity varied, depending on the data sources and characteristics of patients with AD. In studies presenting the results of regression analyses, costs were shown to be independently associated with cognition, functional status, behavioral symptoms, and dependence.

CONCLUSIONS

Published US studies (1) did not include all the types of costs and AD populations, and (2) generally did not include all the measures of disease severity that are needed for cost-effectiveness models.

Small molecule inhibitors of amyloid β peptide aggregation as a potential therapeutic strategy for Alzheimer's disease

Amyloid β (Aβ) peptides have long been viewed as a potential target for Alzheimer's disease (AD). Aggregation of Aβ peptides in the brain tissue is believed to be an exclusively pathological process. Therefore, blocking the initial stages of Aβ peptide aggregation with small molecules could hold considerable promise as the starting point for the development of new therapies for AD. Recent rapid progresses in our understanding of toxic amyloid assembly provide a fresh impetus for this interesting approach. Here, we discuss the problems, challenges and new concepts in targeting Aβ peptides.

Public financial support receipt and non-medical resource utilization in Alzheimer's disease results from the PLASA study

A major health policy objective is to encourage and sustain informal caregiving networks for people with Alzheimer's disease (AD). This goal can be reached by providing financial assistance to patients facing difficulties in the accomplishment of activities of daily living, in order to encourage utilization of professional service and therefore alleviate informal caregiver burden. The main issue is to understand if and how financial assistance is correlated with the distribution between informal and professional care. We used a cross-sectional sample of 1131 French elderly patients (≥65) with mild to moderate AD. Informal and professional service resource use was measured in hours per month using a validated instrument, the Resource Use in Dementia questionnaire. Our results confirmed the utter dominance of informal care, which represented more than 80% of total care even among patients receiving public financial support. However financial support receipt was associated with differences in care utilization: higher use of total non-medical care (formal and informal) and lower proportion of informal care in total non-medical care. Our results suggested the presence of a threshold effect that would influence non-medical care demand decisions. Even if on average the use of informal care in total was 13.3% lower among patients receiving public financial support, informal care use represented more than 80% of total non-medical care use. Providing robust evidence of these associations is crucial to further identify the right dosage between professional service demand and informal care utilization that could be associated with a lower burden and therefore a lower probability of institutionalization.

The economic cost of Alzheimer's disease: Family or public health burden?

Alzheimer’s disease (AD) patients suffer progressive cognitive, behavioral and functional impairment which result in a heavy burden to patients, families, and the public-health system. AD entails both direct and indirect costs. Indirect costs (such as loss or reduction of income by the patient or family members) are the most important costs in early and community-dwelling AD patients. Direct costs (such as medical treatment or social services) increase when the disorder progresses, and the patient is institutionalized or a formal caregiver is required. Drug therapies represent an increase in direct cost but can reduce some other direct or indirect costs involved. Several studies have projected overall savings to society when using drug therapies and all relevant cost are considered, where results depend on specific patient and care setting characteristics. Dementia should be the focus of analysis when public health policies are being devised. South American countries should strengthen their policy and planning capabilities by gathering more local evidence about the burden of AD and how it can be shaped by treatment options.

Differential features of burden between spouse and adult-child caregivers of patients with Alzheimer's disease: an exploratory comparative design

BACKGROUND

Research into burden among spouse and adult-child caregivers of patients with Alzheimer's disease has generated contradictory results as regards the group which suffers the greatest burden and the factors underlying any differences.

OBJECTIVES

The aim of the present study was to identify and compare the factors associated with caregiver burden among spouse and adult-child caregivers.

DESIGN

Cross-sectional analytic study.

SETTINGS

All clinical subjects had been referred on an out-patient basis to the Memory and Dementia Assessment Unit of the Santa Caterina Hospital in Girona (Spain).

PARTICIPANTS

Data were collected from 251 patients and their caregivers, 112 with spouse and 139 with adult-child caregivers.

METHODS

The association between caregiver burden and the socio-demographic and clinical variables of both patients and caregivers was analysed, the results being compared for spouse vs. adult-child caregivers. Burden was analysed using a multivariate linear regression including all the variables for the two groups of caregivers.

RESULTS

The results show greater burden among adult-child caregivers (p<.05), who experience more feelings of guilt (p<.001). In both groups the behavioural and psychological symptoms of patients were correlated with burden (p<.001). Living with the patient has a notable influence on burden among adult children (p<.001). Husbands, wives, daughters and sons, in this order, showed increasing levels of burden (p<.05) and progressively worse mental health (p<.01). However, the correlations between burden and mental health were strongest in daughters (p<.001).

CONCLUSION

The differences in burden between spouse and adult-child caregivers were not associated with age, physical health or clinical factors of the patients. Overall burden was greater among adult-child caregivers, especially those who lived with the patient and who had other family duties. Feelings of guilt were associated with not living with the patient, and there was a strong correlation between burden and mental health. These results support the hypothesis that spouses regard caregiving as part of their marital duties, whereas for adult children such tasks imply an important change in their lifestyle.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The effects of patient function and dependence on costs of care in Alzheimer's disease

OBJECTIVES

To estimate incremental effects of patients' dependence and function on costs of care during the early stages of Alzheimer's disease (AD) and to compare strengths of their relationships with different cost components.

DESIGN

Multicenter, cross-sectional, observational study.

SETTING

Three university hospitals in the United States.

PARTICIPANTS

One hundred seventy-nine community-living patients with probable AD, with modified Mini-Mental State Examination scores of 30 or higher.

MEASUREMENTS

Patients' dependence was measured using the Dependence Scale (DS). Functional capacity was measured using the Blessed Dementia Rating Scale (BDRS). Total cost was measured by summing direct medical costs and informal costs. Direct medical costs included costs of hospitalization, outpatient treatment and procedures, assistive devices, and medications. Informal costs were estimated from time spent helping with basic and instrumental activities of daily living for up to three caregivers per patient using national average hourly earnings as wage rate.

RESULTS

DS and BDRS were associated with higher total cost; a 1-point increase in DS was associated with a $1,832 increase in total cost, and a 1-point increase in BDRS was associated with a $3,333 increase. Examining component costs separately identified potential differences between DS and BDRS. A 1-point increase in BDRS was associated with a $1,406 increase in direct medical cost. A 1-point increase in DS was associated with a $1,690 increase in informal cost.

CONCLUSION

Patients' dependence and function related differently to direct medical and informal cost, suggesting that measures of function and dependence provided unique information for explaining variations in cost of care for patients with AD, highlighting the value in measuring both constructs.