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

Healthcare use according to deprivation among French Alzheimer's Disease and Related Diseases subjects: a national cross-sectional descriptive study based on the FRA-DEM cohort

Introduction

Pluriprofessional and coordinated healthcare use is recommended for Alzheimer's Disease and Related Diseases (ADRD). Despite a protective health system, France is characterized by persistent and significant social inequalities in health. Although social health inequalities are well documented, less is known about social disparities in healthcare use in ADRD, especially in France. Therefore, this study aimed to describe healthcare use according to socioeconomic deprivation among ADRD subjects and the possible potentiating role of deprivation by age.

Methods

We studied subjects identified with incident ADRD in 2017 in the French health insurance database (SNDS). We described a large extent of their healthcare use during the year following their ADRD identification. Deprivation was assessed through French deprivation index (Fdep), measured at the municipality level, and categorized into quintiles. We compared healthcare use according to the Fdep quintiles through chi-square tests. We stratified the description of certain healthcare uses by age groups (40-64 years, 65-74 years, 75-84 years, 85 years, and older), number of comorbidities (0, 1, 2-3, 4 comorbidities and more), or the presence of psychiatric comorbidity.

Results

In total, 124,441 subjects were included. The most deprived subjects had less use of physiotherapy (28.56% vs. 38.24%), ambulatory specialists (27.24% vs. 34.07%), ambulatory speech therapy (6.35% vs. 16.64%), preventive consultations (62.34% vs. 69.65%), and were less institutionalized (28.09% vs. 31.33%) than the less deprived ones. Conversely, they were more exposed to antipsychotics (11.16% vs. 8.43%), benzodiazepines (24.34% vs. 19.07%), hospital emergency care (63.84% vs. 57.57%), and potentially avoidable hospitalizations (12.04% vs. 10.95%) than the less deprived ones.

Discussion and conclusion

The healthcare use of subjects with ADRD in France differed according to the deprivation index, suggesting potential health renunciation as in other diseases. These social inequalities may be driven by financial barriers and lower education levels, which contribute to health literacy (especially for preventive care). Further studies may explore them.

Dementia and glaucoma: Results from a Nationwide French Study between 2006 and 2018

PURPOSE

Glaucoma is the leading cause of irreversible blindness worldwide. The brain and eye share many characteristics, so the eye may provide an easy-access window on brain processes. The aim of the study was to evaluate the link between glaucoma as well as intraocular pressure (IOP)-lowering drops load and all-cause dementia.

METHODS

This was a nested case-control study based on the French national healthcare database from 1 January 2006 to 31 December 2018in individuals aged ≥60 years. We compared cases of incident all-cause dementia with 1:5 controls matched by date of case diagnosis (index date), age, sex, and income. We set a 5-year exposure to glaucoma period ending 2 years before the index date (lag-time period to avoid protopathic bias). The main outcome was glaucoma defined with hospitalization related to POAG and/or dispensations of IOP-lowering drops. The secondary outcome was the IOP-lowering drops load.

RESULTS

In total, 4810 incident all-cause dementia and 24 050 matched controls were analysed (median [IQR] age 82 [10] years; 66.6% women). The prevalence of glaucoma was 14.0% in controls and cases. Risk of all-cause dementia was not associated with glaucoma (crude OR, 1.02; 95% CI [0.93-1.11]; p = 0.7; adjusted OR, 0.99; 95% CI [0.91-1.09]; p = 0.9) or IOP-lowering drops load (p = 0.2).

CONCLUSION

The present study in general population ≥60 years old in France did not find any association between glaucoma and incident all-cause dementia.

Healthcare use patterns before Alzheimer's disease and related diseases identification and future healthcare trajectory

OBJECTIVES

A frequent late Alzheimer's Disease and Related Diseases (ADRD) identification is described and may induce erratic health resource use. We aimed to describe healthcare use patterns preceding ADRD identification.

METHODS

We studied persons aged 65 or older, identified with incident ADRD in 2012 in the French health insurance database. Healthcare use covering a wide range of care in ambulatory and hospital settings during the period ranging from 18 to six months before ADRD identification was studied. The main dimensions of healthcare use patterns before ADRD identification were investigated in three age groups (65-74, 75-84, ≥85) through a multiple correspondence analysis. These dimensions were secondarily interpreted according to the 5-year healthcare trajectory following ADRD identification, qualified as favorable (or not) by experts in the field.

RESULTS

This research studied 36,990 subjects. Four dimensions raised in each age group. Two dimensions' interpretations were retrieved in all age groups: intensity of healthcare use, functional dependency. However, their rank differed along with the qualification of the future healthcare trajectory. Some specificities appeared in some age group. In the 65-74 and 75-84 years groups, there were dimensions reflecting healthcare use related to psychiatric or psycho-behavioral disorders. In the ≥85 group, two dimensions reflected dependency related to other comorbidities, and organised medical follow-up.

CONCLUSION

Several dimensions emerged in line with erratic trajectories before ADRD identification. They underlined the need for actions towards ADRD identification.

Identification of dementia and MCI cases in health information systems: An Italian validation study

Introduction

The identification of dementia cases through routinely collected health data represents an easily accessible and inexpensive method to estimate the prevalence of dementia. In Italy, a project aimed at the validation of an algorithm was conducted.

Methods

The project included cases (patients with dementia or mild cognitive impairment [MCI]) recruited in centers for cognitive disorders and dementias and controls recruited in outpatient units of geriatrics and neurology. The algorithm based on pharmaceutical prescriptions, hospital discharge records, residential long‐term care records, and information on exemption from health‐care co‐payment, was applied to the validation population.

Results

The main analysis was conducted on 1110 cases and 1114 controls. The sensitivity, specificity, and positive and negative predictive values in discerning cases of dementia were 74.5%, 96.0%, 94.9%, and 79.1%, respectively, whereas in detecting cases of MCI these values were 29.7%, 97.5%, 92.2%, and 58.1%, respectively. The variables associated with misclassification of cases were also identified.

Discussion

This study provided a validated algorithm, based on administrative data, which can be used to identify cases with dementia and, with lower sensitivity, also early onset dementia but not cases with MCI.

Potential determinants of unfavourable healthcare utilisation trajectories during the last year of life of people with incident Alzheimer Disease or Related Syndromes: a nationwide cohort study using administrative data

BACKGROUND

people approaching the end-of-life frequently face inappropriate care. With Alzheimer Disease or Related Syndromes (ADRS), end-of-life is characterised by progressive decline, but this period remains difficult to identify. This leads to a lack of anticipation and sometimes with unfavourable healthcare utilisation trajectories (HUTs).

OBJECTIVE

to quantify unfavourable HUTs during the last year of life and identify their potential determinants in both community and nursing-home settings.

DESIGN

nationwide cohort study using administrative database.

SETTING

French community and nursing-home residents.

SUBJECTS

incident ADRS people identified in 2012, who died up to 31 December 2017.

METHODS

we used multidimensional clustering to identify 15 clusters of HUTs, using 11 longitudinal healthcare dimensions during the last year of life. Clusters were qualitatively assessed by pluri-disciplinary experts as favourable or unfavourable HUTs. Individual and contextual potential determinants of unfavourable HUTs were studied by setting using logistic random-effect regression models.

RESULTS

62,243 individuals died before 31 December 2017; 46.8% faced unfavourable end-of-life HUTs: 55.2% in the community and 31.8% in nursing-homes. Individual potential determinants were identified: younger age, male gender, ADRS identification through hospitalisation, shorter survival, life-limiting comorbidities, psychiatric disorders, acute hospitalisations and polypharmacy. In the community, deprivation and autonomy were identified as potential determinants. Contextual potential determinants raised mostly in the community, such as low nurse or physiotherapist accessibilities.

CONCLUSIONS

Nearly half of people with ADRS faced unfavourable HUTs during their last year of life. Individual potential determinants should help anticipate advance care planning and palliative care needs assessment. Contextual potential determinants suggest geographical disparities and health inequalities.

The risk of dementia in patients using psychotropic drugs: Antidepressants, mood stabilizers or antipsychotics

OBJECTIVE

The risk of dementia associated with the use of psychotropic drugs is not fully understood. A nested case-control study was carried out to assess the risk of dementia broadly defined or Alzheimer's disease associated with antidepressants, mood stabilizers or antipsychotics.

METHODS

A cohort was formed from healthcare claim databases including all patients aged 50 and over with a first dispensing of the psychotropic drugs concerned between 2006 and 2017. Patients who developed dementia over the study period were considered as cases. The association between drug exposure prior to a five-year lag time and diagnosis of dementia was assessed by conditional logistic regression models.

RESULTS

No association was found between dementia, either broadly defined or Alzheimer disease, and antidepressant or mood stabilizers. Findings were conflicting with regard to antipsychotics. First- and second-generation antipsychotics (FGA and SGA) were not associated with Alzheimer disease. SGA treatments of more than 3 months were associated with a higher risk of dementia broadly defined than no use of antipsychotics (Odds ratio [OR] 2.00; 95%CI 1.06-3.79; p = 0.03). In a sensitivity analysis using a lag time of 3 years, ever use of SGA and SGA treatments of more than 3 months were associated with a higher risk of dementia broadly defined than no use of antipsychotics (OR 1.71; 1.10-2.67; p = 0.02 and OR 1.84; 1.03-3.32; p = 0.04, respectively).

CONCLUSION

The association between antipsychotics and dementia should be further investigated to establish patients, specific drugs, and patterns of treatment at risk. Prescribers should remain cautious when prescribing them.