Telemedicine and Disparities in Mental Health Service Use Among Community-Dwelling Older Adults With Alzheimer Disease and Related Dementias

OBJECTIVE

To examine disparities in mental health (MH) service utilization, via in-person and telemedicine (ie, tele-MH), by individuals' race, ethnicity, and community socioeconomic status, among community-dwelling older adults with Alzheimer disease and related dementias (ADRD) before and after the expansion of the Centers for Medicare and Medicaid Services' (CMS's) telemedicine policy.

DESIGN

Observational study.

SETTING AND PARTICIPANTS

A total of 3,003,571 community-dwelling Medicare beneficiaries with ADRD between 2019 and 2021 were included in the study.

METHODS

Multiple national data were linked. The unit of analysis was individual-quarter. Three outcomes were defined: any MH visits (in-person or tele-MH), in-person MH visits, and tele-MH visits per quarter. Key independent variables included individual race and ethnicity, the socioeconomic status of the community, and an indicator for the implementation of the telemedicine policy. Regression analyses with individual random effects were used.

RESULTS

In general, Black and Hispanic older adults with ADRD and those in socioeconomically deprived communities were less likely to have MH visits than White adults and those from less-deprived communities. In-person and tele-MH visits varied throughout the pandemic and across subpopulations. For instance, at the beginning of the pandemic, White, Black, and Hispanic older adults experienced 5.05, 3.03, and 2.87 percentage point reductions in in-person MH visits, and 3.53, 1.26, and 0.32 percentage point increases in tele-MH visits (with P < .01 for racial/ethnic differences), respectively. During the pandemic, the increasing trend in in-person MH visits and the decreasing trend in tele-MH visits varied across different subgroups. Overall, racial and ethnic differences in any MH visits were reduced, but the gap in any MH visits between deprived and less-deprived communities doubled during the pandemic (P < .01).

CONCLUSIONS AND IMPLICATIONS

Telemedicine may have provided an opportunity to improve access to MH services among underserved populations. However, although some disparities in MH care were reduced, others widened, underscoring the importance of equitable health care access strategies to address the unique needs of different populations.

Reported Unmet Hearing Aid Need in Older People With Dementia: The US National Core Indicators Survey

OBJECTIVES

Hearing aids have important health benefits for older adults with Alzheimer disease and related dementias (ADRD); however, hearing aid adoption in this group is low. This study aimed to determine where to target hearing aid interventions for American long-term care recipients with ADRD by examining the association of ADRD and residence type with respondent-reported unmet hearing aid need.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the United States National Core Indicators-Aging and Disabilities survey (2015-2019) for long-term care recipients aged ≥65 years.

METHODS

We used multivariable logistic regression to model the likelihood of reporting unmet hearing aid need conditional on ADRD status and residence type (own/family house or apartment, residential care, or nursing facility/home), adjusting for sociodemographic factors and response type (self vs proxy).

RESULTS

Of the 25,492 respondents [median (IQR) age, 77 (71, 84) years; 7074 (27.8%) male], 5442 (21.4%) had ADRD and 3659 (14.4%) owned hearing aids. Residence types were 17,004 (66.8%) own/family house or apartment, 4966 (19.5%) residential care, and 3522 (13.8%) nursing home. Among non-hearing aid owners, ADRD [adjusted odds ratio (AOR) 0.90, 95% CI 0.80-1.0] and residence type were associated with respondent-reported unmet hearing aid need. Compared to the nursing home reference group, respondents in their own/family home (AOR 1.85, 95% CI 1.61-2.13) and residential care (AOR 1.30, 95% CI 1.10-1.53) were more likely to report unmet hearing aid need. This pattern was significantly more pronounced in people with ADRD than in those without, stemming from an interaction between ADRD and residence type.

CONCLUSIONS AND IMPLICATIONS

American long-term care recipients with ADRD living in their own/family home are more likely to report unmet hearing aid need than those with ADRD in institutional and congregate settings. This information can inform the design and delivery of hearing interventions for older adults with ADRD.

Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement

OBJECTIVES

Assess prevalence of serious mental illness (SMI) alone, and co-occurring with Alzheimer disease and related dementias (ADRD), among Medicare beneficiaries in assisted living (AL). Examine the association between permanent nursing home (NH) placement and SMI, among residents with and without ADRD.

DESIGN

2018-2019 retrospective cohort of Medicare beneficiaries in AL. Residents were followed for up to 2 years to track their NH placement. We used data from the Medicare Enrollment Database, the Medicare Beneficiary Summary File, Minimum Data Set, and a national directory of state-licensed AL communities. AL residents were identified using a validated, previously reported 9-digit zip code methodology.

SETTING AND PARTICIPANTS

A cross-sectional study sample included 289,350 Medicare beneficiaries in 17,265 AL communities across 50 states and in the District of Columbia.

METHODS

The outcome was permanent NH placement: a continuous stay for more than 90 days. Key independent variable was presence of SMI-schizophrenia, bipolar disorder, and major depression. Other covariates included sociodemographic factors and presence of other chronic conditions, including ADRD. A linear probability model with robust SEs, and AL-level random effects, was used to test the association between SMI diagnoses, ADRD, and their interactions on NH placement.

RESULTS

More than half (55.65%) of AL residents had a diagnosis of SMI, among them 93.2% had major depression, 28.5% schizophrenia, and 22.2% bipolar disorder. Individuals with schizophrenia and bipolar disorder had a significantly lower probability of NH placement, a 32% and a 15% decrease relative to the cohort mean, respectively. Placement risk was significantly greater for residents with ADRD compared to those without, increasing for those who also had schizophrenia or bipolar disorder, 12.9% and 1.5% relative to the sample mean, respectively.

CONCLUSION AND IMPLICATIONS

Presence of schizophrenia and bipolar disorder, in conjunction with ADRD, significantly increases the risk of long-term NH placement, suggesting that ALs may not be well prepared to care for these residents.

Assisted living residents with dementia: Disparities in mental health services pre and during COVID-19

BACKGROUND

Little is known about mental health among Medicare beneficiaries with Alzheimer's disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL residents with ADRD, pre and during the COVID pandemic, focusing on race/ethnicity and Medicare/Medicaid dual status.

METHODS

A CY2018 cohort of AL residents with ADRD was identified. Outcome was any quarterly in-person or telemedicine mental health visit based on national CY2019-2020 Medicare claims. Key independent variables were individual race/ethnicity and dual status and the AL-level proportion of dual residents. We estimated a linear probability model with random effects and robust standard errors. Quarterly indicators captured service use before and after the onset of the pandemic.

RESULTS

The study included 102,758 fee-for-service Medicare beneficiaries with ADRD in 13,400 ALs. One in five residents had any mental health visits prior to the COVID-19 pandemic. Black residents, and those with dual Medicare/Medicaid eligibility, were significantly less likely to use mental health services prior to and during the pandemic. There were no significant differences in visits via telemedicine by race/ethnicity or individual dual status. Residents in AL communities with a higher proportion of duals had a lower likelihood of visits before and during the pandemic.

CONCLUSIONS/IMPLICATIONS

Mental health service use among AL residents with ADRD was low and declining prior to the pandemic. Telehealth allowed for mental health visits to continue during the pandemic, albeit at a lower level. Residents in ALs with a higher proportion of duals were less likely to have in-person or telehealth visits. The results suggest that some ALs may find it difficult to assure mental health service provision to this vulnerable population.

Analysis of agreement between measures of subjective cognitive impairment and probable dementia in the National Health and Aging Trends Study

BACKGROUND

Subjective cognitive impairment (SCI) measures in population-based surveys offer potential for dementia surveillance, yet their validation against established dementia measures is lacking.

METHODS

We assessed agreement between SCI and a validated probable dementia algorithm in a random one-third sample (n = 1936) of participants in the 2012 National Health and Aging Trends Study (NHATS).

RESULTS

SCI was more prevalent than probable dementia (12.2% vs 8.4%). Agreement between measures was 90.0% and of substantial strength. Misclassification rates were higher among older and less-educated subgroups due to higher prevalence of false-positive misclassification but did not vary by sex or race and ethnicity.

DISCUSSION

SCI sensitivity (63.4%) and specificity (92.5%) against dementia were comparable with similar metrics for the NHATS probable dementia measure against the "gold-standard" Aging, Demographics, and Memory Study-based dementia criteria, implying that population-based surveys may afford cost-effective opportunities for dementia surveillance to assess risk and inform policy.

HIGHLIGHTS

The prevalence of subjective cognitive impairment (SCI) is generally higher than that of a validated measure of probable dementia, particularly within the youngest age group, females, Whites, and persons with a college or higher degree. Percent agreement between SCI and a validated measure of probable dementia was 90.0% and of substantial strength (prevalence- and bias-adjusted kappa, 0.80). Agreement rates were higher in older and less-educated subgroups, driven by the higher prevalence of false-positive disagreement, but did not vary significantly by sex or race and ethnicity. SCI's overall sensitivity and specificity were 63.4% and 92.5%, respectively, against a validated measure of probable dementia, suggesting utility as a low-cost option for dementia surveillance. Heterogeneity in agreement quality across subpopulations warrants caution in its use for subgroup analyses.

Sex differences in Alzheimer's disease blood biomarkers in a Caribbean population of African ancestry: The Tobago Health Study

INTRODUCTION

Alzheimer's disease (AD) is increasing in the Caribbean, especially for persons of African ancestry (PAA) and women. However, studies have mostly utilized surveys without AD biomarkers.

METHODS

In the Tobago Health Study (n = 309; 109 women, mean age 70.3 ± 6.6), we assessed sex differences and risk factors for serum levels of phosphorylated tau-181 (p-tau181), amyloid-beta (Aβ)42/40 ratio, glial fibrillary acidic protein (GFAP), and neurofilament light chain (NfL). Blood samples were from 2010 to 2013 for men and from 2019 to 2023 for women.

RESULTS

Women were more obese, hypertensive, and sedentary but reported less smoking and alcohol use than men (age-adjusted p < 0.04). Compared to men, women had worse levels of AD biomarkers, with higher p-tau181 and lower Aβ42/40, independent of covariates (p < 0.001). In sex-stratified analyses, higher p-tau181 was associated with older age in women and with hypertension in men. GFAP and NfL did not differ by sex.

DISCUSSION

Women had worse AD biomarkers than men, unexplained by age, cardiometabolic diseases, or lifestyle. Studying risk factors for AD in PAA is warranted, especially for women earlier in life.

Impact of dance interventions on the symptoms of dementia: A mixed-methods systematic review

OBJECTIVES

This mixed-methods systematic review determined the impact of dance interventions on symptoms of Alzheimer's disease and related dementias (ADRD) among persons living in residential care.

METHODS

Seven databases (Medline, EMBASE, CINAHL, PsycINFO, Web of Science, Ageline, and AMED) were searched. Studies published before June 2022 that investigated the impact of dance interventions on symptoms of ADRD were eligible for inclusion. Risk of bias was assessed using CASP, ROBINS-I, and ROB-2. Quantitative and qualitative objectives provided a convergent segregate narrative synthesis for the review. The review protocol was registered on PROSPERO (CRD42021220535).

RESULTS

Two quantitative and two qualitative studies met the inclusion criteria. Dance interventions decreased levels of agitation and aggression, and improved behavioural and psychological symptoms.

CONCLUSIONS

Studies suggest that dance interventions reduce the symptoms of dementia through increased expression, emotions, and improved relationships for persons with ADRD. However, the small number of included studies limits these conclusions.

In severe ADNC, hippocampi with comorbid LATE-NC and hippocampal sclerosis have substantially more astrocytosis than those with LATE-NC or hippocampal sclerosis alone

Limbic-predominant age-related TDP-43 encephalopathy neuropathologic change (LATE-NC) and hippocampal sclerosis of aging (HS-A) pathologies are found together at autopsy in ∼20% of elderly demented persons. Although astrocytosis is known to occur in neurodegenerative diseases, it is currently unknown how the severity of astrocytosis is correlated with the common combinations of pathologies in aging brains. To address this knowledge gap, we analyzed a convenience sample of autopsied subjects from the University of Kentucky Alzheimer's Disease Research Center community-based autopsy cohort. The subjects were stratified into 5 groups (n = 51 total): pure ADNC, ADNC + LATE-NC, ADNC + HS-A, ADNC + LATE-NC + HS-A, and low-pathology controls. Following GFAP immunostaining and digital slide scanning with a ScanScope, we measured GFAP-immunoreactive astrocytosis. The severities of GFAP-immunoreactive astrocytosis in hippocampal subfield CA1 and subiculum were compared between groups. The group with ADNC + LATE-NC + HS-A had the most astrocytosis as operationalized by either any GFAP+ or strong GFAP+ immunoreactivity in both CA1 and subiculum. In comparison to that pathologic combination, ADNC + HS or ADNC + LATE-NC alone showed lower astrocytosis. Pure ADNC had only marginally increased astrocytosis in CA1 and subiculum, in comparison to low-pathology controls. We conclude that there appeared to be pathogenetic synergy such that ADNC + LATE-NC + HS-A cases had relatively high levels of astrocytosis in the hippocampal formation.

Dementia Simulation for Family Caregivers of Persons With Dementia: A Scoping Review

BACKGROUND

Alzheimer's disease and related dementias are becoming increasingly prevalent worldwide. Persons with dementia receive substantial assistance from family caregivers over extended periods of time. Family caregivers of persons with dementia are twice as likely to report physical, emotional, and financial challenges related to caregiving compared with other types of family caregivers. Empathy has been demonstrated to improve caregivers' quality of life and their relationships with care recipients.

OBJECTIVE

This scoping review examines the current literature on the effects of dementia simulation on empathy levels in family caregivers of persons with dementia.

METHODS

A librarian-assisted search of 4 databases-PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, and Scopus-was conducted. Key terms included "dementia," "family caregivers," and "simulation." To broaden reference retrieval, "empathy" was not used as a key term but remained an inclusion criterion during reference screening. Data extraction of relevant references was completed.

RESULTS

The search yielded 212 citations. Seven eligible dementia simulation studies were identified, including 1 randomized controlled trial, 3 quasi-experimental studies, and 3 qualitative research studies. Only 3 of the 7 studies focused specifically on family caregivers of persons with dementia.

CONCLUSIONS

Qualitative data supported increased empathy in family caregivers, but quantitative findings on changes in empathy levels were inconclusive. Further research using quantitative or mixed-methods designs is necessary to support benefits of simulation on empathy for family caregivers of persons with dementia.

The disproportionate burden of Alzheimer's disease and related dementias (ADRD) in diverse older adults diagnosed with cancer

INTRODUCTION

Older adults living with Alzheimer's disease and related dementias (ADRD) who are then diagnosed with cancer are an understudied population. While the role of cognitive impairment during and after cancer treatment have been well-studied, less is understood about patients who are living with ADRD and then develop cancer. The purpose of this study is to contribute evidence about our understanding of this vulnerable population.

MATERIALS AND METHODS

This was a retrospective cohort study of a linked, representative family of databases of cancer registries and Medicare administrative claims that make up the SEER-Medicare database. Older adults ages 68 and older with a first primary cancer type: breast, cervical, colorectal, lung, oral, or prostate were eligible for inclusion (N = 337,932). Prevalence estimates of ADRD across cancer types and a 5% non-cancer comparison sample were compared by patient factors.

RESULTS

The overall prevalence of patients who had an ADRD diagnosis anytime in the three years prior to their cancer diagnosis was 5.6%. Patients with ADRD were more likely to be female, older (over age 75), a racial/ethnic minority, single, with multiple chronic conditions, and a tumor diagnosed early (stage I) or were unstaged. Black patients with colorectal and oral cancer had the highest and second highest prevalence of ADRD compared to White patients (13.46% vs 7.95% and 12.64% vs 7.82% respectively, p < .0001). We observed the highest prevalence of ADRD among Black patients for breast (11.85%), cervical (11.98%), lung (8.41%), prostate (4.83), and the 5% sample (9.50%, p > .0001).

DISCUSSION

The higher prevalence of ADRD among Black and Latine older adults with cancer not only aligns with the trend observed in our non-cancer comparison sample, but also, these findings demonstrate the compounded risk experienced by minoritized older adults over the life course. The greater than expected prevalence of patients with ADRD who go on to develop cancer demonstrates better assessment of cognition is urgently needed. Accurate identification of these vulnerable populations is critical to improve assessment, care coordination, and address inequities in screening and treatment planning.

Discrepancies in Patient and Caregiver Ratings of Personality Change in Alzheimer's Disease and Related Dementias

OBJECTIVE

Personality change in Alzheimer's disease and related dementias (ADRD) is complicated by the patient and informant factors that confound accurate reporting of personality traits. We assessed the impact of caregiver burden on informant report of Big Five personality traits (extraversion, agreeableness, conscientiousness, neuroticism, and openness) and investigated the regional cortical volumes associated with larger discrepancies in the patient and informant report of the Big Five personality traits.

METHOD

Sixty-four ADRD participants with heterogeneous neurodegenerative clinical phenotypes and their informants completed the Big Five Inventory (BFI). Caregiver burden was measured using the Zarit Burden Interview. Discrepancy scores were computed as the difference between patient and informant ratings for the BFI. Regional gray matter volumes from T1-weighted 3T MRI were normalized to intracranial volume and related to global Big Five discrepancy scores using linear regression.

RESULTS

Higher levels of caregiver burden were associated with higher informant ratings of patient neuroticism (ß = 0.08, p = .012) and with lower informant ratings of patient agreeableness (ß = 0.11, p = .021) and conscientiousness (ß = 0.04, p = .034) independent of disease severity. Patients with greater Big Five discrepancy scores showed smaller cortical volumes in the right medial prefrontal cortex (β = -5.24, p = .045) and right superior temporal gyrus (β = -7.91, p = .028).

CONCLUSIONS

Informant ratings of personality traits in ADRD can be confounded by the caregiver burden, highlighting the need for more objective measures of personality and behavior in dementia samples. Discrepancies between informant and patient ratings of personality may additionally reflect loss of insight secondary to cortical atrophy in the frontal and temporal structures.

Reminiscence and Digital Storytelling to Improve the Social and Emotional Well-Being of Older Adults With Alzheimer's Disease and Related Dementias: Protocol for a Mixed Methods Study Design and a Randomized Controlled Trial

BACKGROUND

Increasing attention is being given to the growing concerns about social isolation, loneliness, and compromised emotional well-being experienced by young adults and older individuals affected by Alzheimer disease and related dementias (ADRD). Studies suggest that reminiscence strategies combined with an intergenerational approach may yield significant social and mental health benefits for participants. Experts also recommended the production of a digital life story book as part of reminiscence. Reminiscence is typically implemented by trained professionals (eg, social workers and nurses); however, there has been growing interest in using trained volunteers owing to staffing shortages and the costs associated with reminiscence programs.

OBJECTIVE

The proposed study will develop and test how reminiscence offered by trained young adult volunteers using a digital storytelling platform may help older adults with ADRD to improve their social and emotional well-being.

METHODS

The proposed project will conduct a randomized controlled trial to assess the effects of the intervention. The older and young adult participants will be randomly assigned to the intervention (reminiscence based) or control groups and then be randomly matched within each group. Data will be collected at baseline before the intervention, in the middle of the intervention, at end of the intervention, and at 3 months after the intervention. An explanatory sequential mixed methods design will be used to take advantage of the strengths of both quantitative and qualitative methods. The quantitative data from surveys will be entered into SPSS and analyzed using covariate-adjusted linear mixed models for repeated measures to compare the intervention and control groups over time on the major outcomes of participants. Conventional content analysis of qualitative interviews will be conducted using data analysis software.

RESULTS

The project was modified to a telephone-based intervention owing to the COVID-19 pandemic. Data collection started in 2020 and ended in 2022. In total, 103 dyads were matched at the beginning of the intervention. Of the 103 dyads, 90 (87.4%) dyads completed the midtest survey and 64 (62.1%) dyads completed the whole intervention and the posttest survey. Although we are still cleaning and finalizing data analyses, the preliminary results from both quantitative and qualitative data showed promising results of this intergenerational reminiscence approach that benefits both the older adults who have cognitive impairments and the young adult participants.

CONCLUSIONS

Intergenerational reminiscence provided by young adult college student offers promising benefits for both the younger and older generations. Future studies may consider scaling up this pilot into a trackable, replicable model that includes more participants with diverse background (eg, public vs private college students and older adults from other agencies) to test the effectiveness of this intervention for older adults with ADRD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05984732; https://classic.clinicaltrials.gov/ct2/show/NCT05984732.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49752.

Female caregivers' contextual complexities and familial power structures within Alzheimer's care

In 2021, 11.3 million unpaid caregivers of persons with Alzheimer's disease/Alzheimer's disease and related dementias (AD/ADRD) provided 16 billion hours of unpaid caregiving worth $271.6 billion. This study aimed to fully capture the contextual complexities of the caregiving role acquisition articulated by female family caregivers of those with AD/ADRD, emphasizing assigned meaning to one's lived experience with a critical focus on how family power structures influence caregiving practices. Recorded open structured interview transcripts (N = 30) from two qualitative studies with the same two opening questions resulted in a corpus of 481 pages of pooled textual data. The data were analyzed using Utrecht's descriptive and interpretive thematic analysis approach. The interpretive thematic analysis uncovered the theme of intervening to protect and its subthemes of financial exploitation, mistreatment, and endangerment. Based on the evolving analysis, we reanalyzed the data using critical discourse analysis (CDA), drawing from Foucault and feminist CDA to explore the complex but subtle nuances of gender, power, and ideologies. CDA uncovered the theme of compulsory altruism. Ambiguity about violating personhood delayed responses to potentially dangerous behavior and actual harm. Using interpretive thematic and critical discourse analysis, we discovered a deeper understanding of female caregivers' contextual complexities, their journey to becoming a caregiver of a family member with AD/ADRD, and the power structures that relegated caregiving to female family members. This research identified a substantial policy gap in supporting female family caregivers who provide the majority of care to persons with AD/ADRD risking their health and financial security.

Testing an Intervention to Improve Posthospital Outcomes in Persons Living With Dementia and Their Family Care Partners

Background and Objectives

Hospitalized persons living with dementia are at risk for functional decline, behavioral symptoms of distress, and delirium, all persisting in the postacute period. In turn, family care partners (FCPs) experience increased anxiety and lack of preparedness for caregiving, compounding existing strain and burden. Family-centered Function-focused Care (Fam-FFC) purposefully engages FCPs in assessment, decision-making, care delivery, and evaluation of function-focused care during and after hospitalization (within 48 hours of discharge, weekly telephone calls for a total of 7 additional weeks, then monthly for 4 months). The objective of this study was to test the efficacy of Fam-FFC.

Research Design and Methods

A cluster randomized controlled trial included 455 dyads of persons living with dementia and FCPs in 6 medical units in 3 hospitals. Patient outcomes included return to baseline physical function, behavioral symptoms of distress, depressive symptoms, and delirium severity. Family care partner measures included preparedness for caregiving, anxiety, strain, and burden.

Results

Multilevel level modeling demonstrated that the likelihood of returning to baseline function across time for Fam-FFC participants was twice that of the control group by the end of 6 months (OR = 2.4, p = .01, 95% CI 1.2-4.7). Family-centered Function-focused Care was also associated with fewer symptoms of distress (b = -1.1, SE = 0.56, p = .05) but no differences in the amount of moderate physical activity, depressive symptoms, and delirium severity. Preparedness for caregiving increased significantly only from 2 to 6 months (b = 0.89, SE = 0.45, d = 0.21, overall p = .02) in the intervention group, with no group differences in anxiety, strain, and burden.

Discussion and Implications

Family-centered Function-focused Care may help prevent some of the postacute functional decline and behavioral symptoms in hospitalized persons living with dementia. Further research is needed to promote sustained improvements in these symptoms with more attention to the postacute needs of the care partner.

The structural and social determinants of Alzheimer's disease related dementias

INTRODUCTION

The projected growth of Alzheimer's disease (AD) and AD-related dementia (ADRD) cases by midcentury has expanded the research field and impelled new lines of inquiry into structural and social determinants of health (S/SDOH) as fundamental drivers of disparities in AD/ADRD.

METHODS

In this review, we employ Bronfenbrenner's ecological systems theory as a framework to posit how S/SDOH impact AD/ADRD risk and outcomes.

RESULTS

Bronfenbrenner defined the "macrosystem" as the realm of power (structural) systems that drive S/SDOH and that are the root cause of health disparities. These root causes have been discussed little to date in relation to AD/ADRD, and thus, macrosystem influences, such as racism, classism, sexism, and homophobia, are the emphasis in this paper.

DISCUSSION

Under Bronfenbrenner's macrosystem framework, we highlight key quantitative and qualitative studies linking S/SDOH with AD/ADRD, identify scientific gaps in the literature, and propose guidance for future research.

HIGHLIGHTS

Ecological systems theory links structural/social determinants to AD/ADRD. Structural/social determinants accrue and interact over the life course to impact AD/ADRD. Macrosystem is made up of societal norms, beliefs, values, and practices (e.g., laws). Most macro-level determinants have been understudied in the AD/ADRD literature.

Impact of interhospital transfer on patients with Alzheimer's disease and other related dementias

Older adults are often transferred from one emergency department (ED) to another hospital for speciality care, but little is known about whether those transfers positively impact patients, particularly those with Alzheimer's disease and other related dementias (ADRD). In this study we aimed to describe the impact of interhospital transfer on older adults with and without ADRD. In a retrospective review of electronic medical records, we collected data on demographics, insurance type, initial code status, intensive care, length of stay, specialist consult, procedure within 48 hours, and discharge disposition for older adults (≥ 65 years). We included older adults with at least one ED visit, who were transferred to a tertiary care hospital. With logistic regression, we estimated odds of death, intensive care stay, or procedure within 48 hours by ADRD diagnosis. Patients with ADRD more often received a geriatrics (p < 0.001) or palliative care consult (p = 0.038). They were less likely to be full code at admission (p < 0.001) or to be discharged home (p < 0.001). Patients living with ADRD less often received intensive care or a procedure within 48 hours of transfer (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.22-2.88). Patients with ADRD were less likely to receive intensive care unit admission or specialist procedures after transfer. Further study is indicated to comprehensively understand patient-centered outcomes.

If Midlife Brain Injury Is a Risk Factor for Alzheimer's Disease and Related Dementias, What Is the Neuropathologic Mechanism?

While we know that brain injuries related to sport and military activities sometimes lead to cognitive impairment or early onset dementia, it is unclear if and how they might influence the development of Alzheimer's Disease and Related Dementias (ADRD). Published analytic conclusions have been mixed. Two reports in the Journal of Alzheimer's Disease reach the same answer: a history of brain injury appears to be a risk factor for generalized brain atrophy, which would likely increase vulnerability to the subsequent development of any variety of ADRD, or to dementia directly attributable to reduced brain mass.

Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter?

OBJECTIVE

To examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

The study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017.

METHODS

2010-2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a "choice" set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies.

RESULTS

Among the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01).

CONCLUSIONS AND IMPLICATIONS

Black individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.

The Senior Companion Program Plus (SCP Plus): Examining the Preliminary Effectiveness of a Lay Provider Program to Support African American Alzheimer's Disease and Related Dementias (ADRD) Caregivers

OBJECTIVES

A culturally informed, peer-led, lay provider model, the Senior Companion Program (SCP) Plus, was implemented to decrease caregiving burden/stress and improve coping skills and social support for African American ADRD caregivers. This study reported the preliminary effectiveness of this intervention.

METHODS

An explanatory sequential mixed methods design was used in this study, and a randomized control trial was conducted for the SCP Plus intervention among participants in three sites (n = 20). A subsample of participants (n = 7) consented to a qualitative interview about their experiences with the intervention. Wilcoxon signed-rank tests, Friedman tests, and one-way repeated measures ANOVA were computed for quantitative analyses. Thematic analysis was used for the qualitative interviews.

RESULTS

Results demonstrated that knowledge of AD/dementia (KAD) and preparedness for caregiving were significantly improved for all senior companions in the intervention group. Results also showed that caregivers in the intervention group reported significantly decreased caregiving burden, as well as increased KAD, satisfaction with social support, and positive aspects of caregiving. Themes from the qualitative interviews included: learning new skills about caregiving, gaining knowledge about ADRD, and benefits for the dyad.

DISCUSSIONS

Findings from this study implied that SCP Plus was a promising model for African American family caregivers as it benefits both the SC volunteers and the African American ADRD family caregivers.

Did the COVID-19 Pandemic Affect the Use of Antipsychotics Among Nursing Home Residents With ADRD?

OBJECTIVE

To examine whether and how the COVID-19 pandemic affected the use of antipsychotics among residents with Alzheimer's disease and related dementias in nursing homes.

DESIGN

Observational study based on the Minimum Data Set and Medicare claims.

SETTING

Medicare- and/or Medicaid-certified nursing homes.

PARTICIPANTS

Nursing home residents diagnosed with Alzheimer's disease and related dementias between 2017 and 2020.

MEASUREMENTS

The main outcome variable was any antipsychotic use during a quarter. The secondary outcome was certified nursing assistants' staffing hours per bed per day in a quarter. We categorized nursing homes into quartiles based on the distribution of nursing home racial and/or ethnic composition. To explore the relationship between the COVID-19 pandemic and the frequency of antipsychotic use, we estimated a linear probability model with robust standard errors, individual and facility random effects. We used a similar model for certified nursing assistant hours.

RESULTS

About 23.7% of residents with ADRD had antipsychotic uses during the study period. The frequency of antipsychotic use declined from 23.7%-23.1% between the first quarter of 2017 (2017Q1) and the first quarter of 2020 (2020Q1) but increased to 24.8% by the last quarter of 2020 (2020Q4). Residents in all four racial and/or ethnic groups experienced an increase in antipsychotic use during the COVID-19 pandemic, but the extent of the increase varied by race and/or ethnicity. For example, while residents in the very-high minority nursing homes experienced a greater increase in antipsychotic use than did the residents of other nursing homes at the beginning of the pandemic, the increasing trend during the pandemic was smaller in the very-high minority nursing homes compared to the low-minority nursing homes (0.2 percentage points less, p<0.001, based on heteroskedasticity-robust t statistics, t = 3.67, df = 8,155,219). On average, the certified nursing assistant hours decreased from 1.8-1.7 hours per bed per day between 2017Q1 and 2020Q1, and further decreased to 1.5 hours per bed per day by 2020Q4. There was also a decreasing trend in staffing hours across all racial and/or ethnic groups during the pandemic.

CONCLUSIONS AND RELEVANCE

The COVID-19 pandemic was associated with an increase in the use of antipsychotics among nursing home residents with Alzheimer's disease and related dementias and decreased staffing of certified nursing assistants, especially among nursing homes with a high minority penetration. Future research is needed to explore means for reducing antipsychotic use, particularly in homes with a high penetration of minority residents.

A Web-Based Decision Aid for Caregivers of Persons With Dementia With Firearm Access (Safe at Home Study): Protocol for a Randomized Controlled Trial

BACKGROUND

Firearm safety among individuals with Alzheimer disease and related dementias (ADRD) is an underdiscussed and underresearched concern in the United States, especially given the growing population of community-dwelling adults with ADRD. The "Safety in Dementia" (SiD) web-based decision aid was developed to support caregivers in addressing firearm access; the efficacy of SiD is unknown.

OBJECTIVE

Through the SiD decision aid, the Safe at Home (S@H) study aims to support caregivers in making decisions about home safety that align with their goals and values, and behaviors regarding firearm access for persons with ADRD and firearm access.

METHODS

The S@H study is a 2-armed randomized controlled trial to test the effect of the SiD decision aid on caregivers of community-dwelling adults with ADRD who have firearm access. S@H aims to recruit 500 ADRD caregivers (age ≥18 years, fluent in English or Spanish, and in the United States) through online or social media advertisements and through relevant organizations. Participants are randomized to view SiD or a control website at their own pace; all participants complete web-based questionnaires at baseline, 2 weeks, 2 months, and 6 months. The primary outcome is immediate preparation for decision-making; secondary outcomes include longitudinal decision outcomes and self-reported modifications to firearm access. The relative reach and effectiveness of each recruitment method (online/social media and through relevant organizations) will be assessed by examining differences in caregiver participation, retention rates, and relative cost.

RESULTS

The study enrollment began in May 2022. As of December 2022, a total of 117 participants had enrolled.

CONCLUSIONS

The S@H study is the first randomized trial of a firearm safety decision aid for ADRD caregivers. The results from this study will inform how best to support caregivers in decision-making regarding firearm safety. Further, results may guide approaches for recruiting caregivers and for dissemination of resources.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05173922; https://clinicaltrials.gov/ct2/show/NCT05173922.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43702.

Caring for Dementia Caregivers: Understanding Caregiver Stress During the COVID-19 Pandemic

More than 16 million Americans provide unpaid care for someone with Alzheimer's disease and related dementias (ADRD). During the COVID-19 pandemic, unpaid caregivers experienced increased chronic severe stress from widespread closures and social distancing. We conducted eight surveys from March 2020 to March 2021 among a cohort of over 10,000 individuals. Cross-sectional analysis was conducted to investigate frequency and ratios of groups reporting increased stress across surveys. A longitudinal analysis was also performed with the 1,030 participants who took more than one survey. We found a growing crisis among dementia caregivers: By Survey 8, current caregivers reported 2.9 times higher stress levels than the comparator group. By that time, 64% of current caregivers reported having multiple stress symptoms typically found in people experiencing severe stress. Both analyses reported increased levels of stressors over time that were more associated with certain caregiver groups. Our findings underscore the urgent need for public policy initiatives and supportive community infrastructure to support ADRD caregivers.

Statistical harmonization of everyday functioning and dementia-related behavioral measures across nine surveys and trials

Introduction

Efforts to harmonize measures of everyday function and dementia-related behaviors are needed to synthesize across studies in dementia research. There have been some psychometric attempts to harmonize everyday function for secondary analysis, but far less for dementia-related behaviors.

Methods

Statistical co-calibration was performed to generate factor scores representing everyday function and dementia-related behaviors for participants with dementia. We evaluated convergent criterion validity of factor scores and mapped the scores onto established clinical instruments.

Results

Factor analyses of included items fit well to available data. Harmonized factors showed expected associations with the Global Clinical Dementia Rating (CDR) score, with greater impairment (higher Global CDR score) corresponding to higher (more severe) levels on factor scores.

Discussion

We used large, well-characterized samples to derive harmonized factors representing everyday functions and dementia-related behaviors. These harmonized factors can be used to tackle questions about dementia phenotypes which require either large samples or unique subpopulations.

An HIT-Supported Care Coordination Framework for Reducing Structural Racism and Discrimination for Patients With ADRD

Black and Latinx Americans are disproportionately at greater risk for having Alzheimer's disease and related dementias (ADRD) than White Americans. Such differences in risk for ADRD are arguably explained through health disparities, social inequities, and historical policies. Structural racism and discrimination (SRD), defined as "macro-level conditions that limit opportunities, resources, and well-being of less privileged groups," have been linked with common comorbidities of ADRD, including hypertension, obesity, diabetes, depression. Given the historical impact of SRD-including discriminatory housing policies resulting in racial residential segregation that has been shown to limit access to education, employment, and healthcare-Black and Latinx populations with ADRD are directly or indirectly negatively affected by SRD in terms of access, quality and cost for healthcare. Emerging studies have brought to light the value of structural-level hospital and public health collaboration on care coordination for improving healthcare quality and access, and thus could serve as a macro-level mechanism for addressing disparities for minoritized racial and ethnic populations with ADRD. This paper presents a conceptual framework delineating how care coordination can successfully be achieved through health information technology (HIT) systems and ultimately address SRD. To address health inequities, it is therefore critical that policy initiatives invest in HIT capacities and infrastructures to promote care coordination, identify patient needs and preferences, and promote engagement of patients with ADRD and their caregivers.

The relationship of caregiver self-efficacy to caregiver outcomes: a correlation and mediation analysis

OBJECTIVES

Caregivers of individuals with Alzheimer's disease and related dementias experience significant burden and adverse outcomes. Enhancing caregiver self-efficacy has the potential to mitigate these negative impacts, yet little is known about its relationship with other aspects of caregiving. This study examined the relationship between self-efficacy and outcomes; identified factors associated with self-efficacy; examined the mediating role of self-efficacy; and analyzed whether there were racial/ethnic differences.

METHODS

Data from caregivers (N = 243) were collected from the Caring for the Caregiver Network study. Participants' level of self-efficacy, depression, burden, and positive aspects of caregiving was assessed using validated measures.

RESULTS

Two self-efficacy subscales predicted caregiver depression, burden, and positive aspects of caregiving. Being White, a spouse, or having a larger social network predicted lower self-efficacy for obtaining respite. Higher income and lower preparedness predicted lower self-efficacy for controlling upsetting thoughts and responding to disruptive behaviors. Self-efficacy for controlling upsetting thoughts mediated the relationship between preparedness and depression along with the relationship between preparedness and burden. Race/ethnicity did not improve model fit.

CONCLUSION

Self-efficacy plays an important role in caregiver outcomes. These findings indicate that strategies to improve caregiver self-efficacy should be an integral component of caregiver interventions.

Global and regional projections of the economic burden of Alzheimer's disease and related dementias from 2019 to 2050: A value of statistical life approach

BACKGROUND

The burden of Alzheimer's disease and related dementias (ADRDs) is expected to grow rapidly with population aging, especially in low- and middle-income countries, in the next few decades. We used a willingness-to-pay approach to project the global, regional, and national economic burden of ADRDs from 2019 to 2050 under status quo.

METHODS

We projected age group and country-specific disability-adjusted life years (DALYs) lost to ADRDs in future years based on historical growth in disease burden and available population projections. We used country-specific extrapolations of the value of a statistical life (VSL) year and its future projections based on historical income growth to estimate the economic burden - measured in terms of the value of lost DALYs - of ADRDs. A probabilistic uncertainty analysis was used to calculate point estimates and 95% uncertainty bounds of the economic burden.

FINDINGS

In 2019, the global VSL-based economic burden of ADRDs was an estimated $2.8 trillion. The burden was projected to increase to $4.7 trillion (95% uncertainty bound: $4 trillion-$5.5 trillion) in 2030, $8.5 trillion ($6.8 trillion-$10.8 trillion) in 2040, and $16.9 trillion ($11.3 trillion-$27.3 trillion) in 2050. Low- and middle-income countries (LMICs) would account for 65% of the global VSL-based economic burden in 2050, as compared with only 18% in 2019. Within LMICs, upper-middle income countries would carry the largest VSL-based economic burden by 2050 (92% of LMICs burden and 60% of global burden).

INTERPRETATION

ADRDs have a large and inequitable projected future VSL-based economic burden.

FUNDING

The Davos Alzheimer's Collaborative.

Challenges and progress in research, diagnostics, and therapeutics in Alzheimer's disease and related dementias

The health, well-being, and financial security of Americans are greatly impacted by Alzheimer's disease. The forecast paints an upward trajectory with the number of Americans suffering from Alzheimer's disease and related dementia. To discuss the Alzheimer's crisis, The Senate Committee on Finance, Subcommittee on Health Care, held a hearing titled, "The Alzheimer's Crisis: Examining, Testing, and Treatment Pipelines and Fiscal Implications," on December 16, 2020. Here, we summarize and expand on the discussion of the panel and its review of recent progress, ongoing challenges associated with Alzheimer's disease, and potential initiatives that promise to speed progress in developing treatments and improving care.

Frequency of LATE neuropathologic change across the spectrum of Alzheimer's disease neuropathology: combined data from 13 community-based or population-based autopsy cohorts

Limbic-predominant age-related TDP-43 encephalopathy neuropathologic change (LATE-NC) and Alzheimer's disease neuropathologic change (ADNC) are each associated with substantial cognitive impairment in aging populations. However, the prevalence of LATE-NC across the full range of ADNC remains uncertain. To address this knowledge gap, neuropathologic, genetic, and clinical data were compiled from 13 high-quality community- and population-based longitudinal studies. Participants were recruited from United States (8 cohorts, including one focusing on Japanese-American men), United Kingdom (2 cohorts), Brazil, Austria, and Finland. The total number of participants included was 6196, and the average age of death was 88.1 years. Not all data were available on each individual and there were differences between the cohorts in study designs and the amount of missing data. Among those with known cognitive status before death (n = 5665), 43.0% were cognitively normal, 14.9% had MCI, and 42.4% had dementia-broadly consistent with epidemiologic data in this age group. Approximately 99% of participants (n = 6125) had available CERAD neuritic amyloid plaque score data. In this subsample, 39.4% had autopsy-confirmed LATE-NC of any stage. Among brains with "frequent" neuritic amyloid plaques, 54.9% had comorbid LATE-NC, whereas in brains with no detected neuritic amyloid plaques, 27.0% had LATE-NC. Data on LATE-NC stages were available for 3803 participants, of which 25% had LATE-NC stage > 1 (associated with cognitive impairment). In the subset of individuals with Thal Aβ phase = 0 (lacking detectable Aβ plaques), the brains with LATE-NC had relatively more severe primary age-related tauopathy (PART). A total of 3267 participants had available clinical data relevant to frontotemporal dementia (FTD), and none were given the clinical diagnosis of definite FTD nor the pathological diagnosis of frontotemporal lobar degeneration with TDP-43 inclusions (FTLD-TDP). In the 10 cohorts with detailed neurocognitive assessments proximal to death, cognition tended to be worse with LATE-NC across the full spectrum of ADNC severity. This study provided a credible estimate of the current prevalence of LATE-NC in advanced age. LATE-NC was seen in almost 40% of participants and often, but not always, coexisted with Alzheimer's disease neuropathology.

Comparing emergency department use among individuals with varying levels of cognitive impairment

INTRODUCTION

As the population ages, Alzheimer's disease and related dementias (ADRD) are becoming increasingly common in patients presenting to the emergency department (ED). This study compares the frequency of ED use among a cohort of individuals with well-defined cognitive performance (cognitively intact, mild cognitive impairment (MCI), and ADRD).

METHODS

We performed a retrospective cohort study of English-speaking, community-dwelling individuals evaluated at four health system-based multidisciplinary memory clinics from 2014-2016. We obtained demographic and clinical data, including neuropsychological testing results, through chart review and linkage to electronic health record data. We characterized the frequency and quantity of ED use within one year (6 months before and after) of cognitive evaluation and compared ED use between the three groups using bivariate and multivariate approaches.

RESULTS

Of the 779 eligible patients, 89 were diagnosed as cognitively intact, 372 as MCI, and 318 as ADRD. The proportion of subjects with any annual ED use did not increase significantly with greater cognitive impairment: cognitively intact (16.9%), MCI (26.1%), and ADRD (28.9%) (p = 0.072). Average number of ED visits increased similarly: cognitively intact (0.27, SD 0.72), MCI (0.41, SD 0.91), and ADRD (0.55, SD 1.25) (p = 0.059). Multivariate logistic regression results showed that patients with MCI (odds ratio (OR) 1.62; CI = 0.87-3.00) and ADRD (OR 1.84; CI = 0.98-3.46) did not significantly differ from cognitively intact adults in any ED use. Multivariate negative binomial regression found patients with MCI (incidence rate ratio (IRR) 1.38; CI = 0.79-2.41) and ADRD (IRR 1.76, CI = 1.00-3.10) had elevated but non-significant risk of an ED visit compared to cognitively intact individuals.

CONCLUSION

Though there was no significant difference in ED use in this small sample from one health system, our estimates are comparable to other published work. Results suggested a trend towards higher utilization among adults with MCI or ADRD compared to those who were cognitively intact. We must confirm our findings in other settings to better understand how to optimize systems of acute illness care for individuals with MCI and ADRD.

The Diagnosis of Schizophrenia Among Nursing Home Residents With ADRD: Does Race Matter?

OBJECTIVE

To examine racial differences in the frequency of schizophrenia diagnosis codes used among nursing home (NH) residents with Alzheimer's Disease and Related Dementias (ADRD), pre and post the implementation of public reporting of antipsychotic use in NHs.

METHODS

The 2011-2017 Minimum Data Set and Medicare Master Beneficiary Summary File were linked. We identified long-stay NH residents (i.e., those who had quarterly or annual assessments) with ADRD aged 55 years and older (N = 7,734,348). Outcome variable was defined as the diagnosis of schizophrenia documented in the MDS assessments. Main variables of interest included individual race (black versus white), the percent of blacks in a NH and time trend. Multivariate regressions were estimated.

RESULTS

The frequency of schizophrenia diagnosis codes among NH residents with ADRD steadily increased over the study period, and blacks experienced a greater increase than their white counterparts. For example, the overall likelihood of having schizophrenia diagnosis increased 1.9 percentage points (95% confidence interval [CI]: 0.019, 0.020, p < 0.01) from 2011 to 2017 among whites, while blacks had an addition 1.3 percentage points increase (95% CI: 0.011, 0.015, p < 0.01). The increase in the likelihood of having schizophrenia diagnosis code was higher in NHs with higher percent of blacks: the increase from 2011 to 2017 was 2.6 percentage point (95% CI: 0.023, 0.029, p < 0.01) higher in NHs with the highest percent of blacks, compared to NHs with lowest percent of blacks. Racial differences in the growth of schizophrenia diagnosis also existed within a NH after accounting for NH factors.

CONCLUSION

Following the implementation of public reporting of antipsychotic use in NH, black residents experienced a greater increase in the likelihood of having schizophrenia diagnosis than white NH residents. NHs with a higher proportion of blacks had a greater increase in schizophrenia diagnosis, and blacks experienced an increased likelihood of schizophrenia diagnosis than whites within a NH. Further research is needed to determine a causal relationship between the federal policy mandating public reporting and disparities in schizophrenia diagnostic coding.

Comparing the care experiences of Medicare Advantage beneficiaries with and without Alzheimer's disease and related dementias

BACKGROUND

The Medicare Advantage (MA) program is rapidly growing. Limited evidence exists about the care experiences of MA beneficiaries with Alzheimer's Disease and Related Dementia (ADRD). Our objective was to compare care experiences for MA beneficiaries with and without ADRD.

METHODS

We examined MA beneficiaries who completed the Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) and used inpatient, nursing home, or home health services in the past 3 years. We classified beneficiaries with ADRD using the presence of diagnosis codes in hospitals, nursing homes, and home health records. Our key measures included overall ratings of care and health plan, and indices of receiving timely care, care coordination, receiving needed care, and customer service. We compared differences between beneficiaries with and without ADRD using regression analysis adjusting for demographic, health, and plan characteristics, and stratifying by proxy response status.

RESULTS

Among beneficiaries sampled by CAHPS, 22.2% with ADRD completed the survey compared to 38.5% without ADRD. Among proxy responses, beneficiaries with ADRD were 4.2 (95% CI: 0.1-8.4) percentage points less likely to report a high score for receiving needed care, and 3.5 percentage points (95% CI: 0.2-6.9) less likely to report a high score for customer service. Among non-proxy responses, those with ADRD were 9.0 (95% CI: 5.5-12.5) percentage points less likely to report a high score for needed care, and 8.5 (95% CI: 5.4-11.5) percentage points less likely to report a high score for customer service.

CONCLUSIONS

ADRD respondents to the CAHPS were more likely to be excluded from CAHPS performance measures because they did not meet eligibility requirements and rates of non-response were higher. Among responders with or without a proxy, MA enrollees with an ADRD diagnosis reported worse care experiences in receiving needed care and in customer service than those without an ADRD diagnosis.

Self-reported measures of limitation in physical function in late midlife are associated with incident Alzheimer's disease and related dementias

BACKGROUND

Even small improvements in modifiable Alzheimer's disease and related dementias (ADRD) risk factors could lead to a substantial reduction of dementia cases.

AIMS

To determine if self-reported functional limitation associates with ADRD symptoms 4-18 years later.

METHODS

We conducted a prospective longitudinal study using the Health and Retirement Study of adults aged 51-59 years in 1998 without symptoms of ADRD by 2002 and followed them to 2016. Main exposure variables were difficulty with activities of daily living, mobility, large muscle strength, gross motor and upper limb activities. The outcome was incident ADRD identified by the Lange-Weir algorithm, death, or alive without ADRD. We fit two GEE multinomial models for each measure: (1) baseline measure of function and (2) change in function over time.

RESULTS

In the model with baseline only and outcome, only difficulty with mobility associated with future ADRD across levels of difficulty with near dose-response effect (risk ratios (RR) difficulty with 1-5 functions respectively, compared with no difficulty: 1.82; 2.70; 1.73 2.81; 4.03). Mobility also significantly associated with ADRD when allowing for change over time among those with 3, 4 or 5 versus no mobility limitations (RR 1.76; 2.36; 2.37).

DISCUSSION

The results infer that an adult in midlife reporting difficulty with mobility as well as those with no mobility limitations in midlife but who later report severe limitations may be at increased risk of incident ADRD.

CONCLUSIONS

Self-reported measures of mobility limitation may be early indicators of ADRD and may be useful for public health planning.

Association between WWOX/MAF variants and dementia-related neuropathologic endophenotypes

The genetic locus containing the WWOX and MAF genes was implicated as a clinical Alzheimer's disease (AD) risk locus in two recent large meta-analytic genome wide association studies (GWAS). In a prior GWAS, we identified a variant in WWOX as a suggestive risk allele for hippocampal sclerosis. We hypothesized that the WWOX/MAF locus may be preferentially associated with non-plaque- and non-tau-related neuropathological changes (NC). Data from research participants with GWAS and autopsy measures from the National Alzheimer's Coordinating Center and the Religious Orders Study and the Rush Memory and Aging Project were meta-analyzed. Notably, no variants in the locus were significantly associated with ADNC. However, several WWOX/MAF variants had significant adjusted associations with limbic-predominant age-related TDP-43 encephalopathy NC (LATE-NC), HS, and brain arteriolosclerosis. These associations remained largely unchanged after adjustment for ADNC (operationalized with standard semiquantitative staging), suggesting that these associations are independent of ADNC. Thus, WWOX genetic variants were associated pathologically with LATE-NC, not ADNC.

Domains of delirium severity in Alzheimer's disease and related dementias

BACKGROUND

The ability to rate delirium severity is key to providing optimal care for persons with Alzheimer's Disease and Related Dementias (ADRD). Such ratings would allow clinicians to assess response to treatment, recovery time and prognosis, nursing burden and staffing needs, and to provide nuanced, appropriate patient-centered care. Given the lack of existing tools, we defined content domains for a new delirium severity instrument for use in individuals with mild to moderate ADRD, the DEL-S-AD.

METHODS

We built upon our previous study in which we created a content domain framework to inform development of a general delirium severity instrument, the DEL-S. We engaged a new expert panel to discuss issues of measurement in delirium and dementia and to determine which content domains from the prior framework were useful in characterizing delirium severity in ADRD. We also asked panelists to identify new domains. Our panel included eight interdisciplinary members with expertise in delirium and dementia. Panelists participated in two rounds of review followed by two surveys over 2 months.

RESULTS

Panelists endorsed the same content domains as for general delirium severity, including Cognitive, Level of Consciousness, Inattention, Psychiatric-Behavioral, Emotional Dysregulation, Psychomotor Features, and Functional; however, they excluded six of the original subdomains which they considered unhelpful in the context of ADRD: cognitive impairment; anxiety; fear/sense of unease; depression; gait/walking; and incontinence. Debated measurement challenges included assessment at one point in time versus over time, accounting for differences in clinical settings, and accurate assessment of symptoms related to delirium versus dementia.

CONCLUSIONS

By capturing a range of characteristics of delirium severity potentially present in patients with ADRD, a population that may already have attention, functional, and emotional changes at baseline, the DEL-S-AD provides a novel rating tool that will be useful for clinical and research purposes to improve patient care.

Pre-statistical harmonization of behavrioal instruments across eight surveys and trials

BACKGROUND

Data harmonization is a powerful method to equilibrate items in measures that evaluate the same underlying construct. There are multiple measures to evaluate dementia related behavioral symptoms. Pre-statistical harmonization of behavioral instruments in dementia research is the first step to develop a statistical crosswalk between measures. Studies that conduct pre-statistical harmonization of behavioral instruments rarely document their methods in a structured, reproducible manner. This is a crucial step which entails careful review, documentation and scrutiny of source data to ensure sufficient comparability between items prior to data pooling. Here, we document the pre-statistical harmonization of items measuring behavioral and psychological symptoms among people with dementia. We provide a box of recommended procedure for future studies.

METHODS

We identified behavioral instruments that are used in clinical practice, a national survey, and randomized trials of dementia care interventions. We rigorously reviewed question content and scoring procedures to establish sufficient comparability across items as well as item quality prior to data pooling. Additionally, we standardized coding to Stata-readable format, which allowed us to automate approaches to identify potential cross-study differences in items and low-quality items. To ensure reasonable model fit for statistical co-calibration, we estimated two-parameter logistic Item Response Theory models within each of the eight studies.

RESULTS

We identified 59 items from 11 behavioral instruments across the eight datasets. We found considerable cross-study heterogeneity in administration and coding procedures for items that measure the same attribute. Discrepancies existed in terms of directionality and quantification of behavioral symptoms for even seemingly comparable items. We resolved item response heterogeneity, missingness and skewness, conditional dependency prior to estimation of item response theory models for statistical co-calibration. We used several rigorous data transformation procedures to address these issues, including re-coding and truncation.

CONCLUSIONS

This study highlights the importance of each aspect involved in the pre-statistical harmonization process of behavioral instruments. We provide guidelines and recommendations for how future research may detect and account for similar issues in pooling behavioral and related instruments.

Disproportionate increases in schizophrenia diagnoses among Black nursing home residents with ADRD

BACKGROUND

Previous research demonstrated an increase in the reporting of schizophrenia diagnoses among nursing home (NH) residents after the Centers for Medicare & Medicaid Services National Partnership to Improve Dementia Care. Given known health and healthcare disparities among Black NH residents, we examined how race and Alzheimer's and related dementia (ADRD) status influenced the rate of schizophrenia diagnoses among NH residents following the partnership.

METHODS

We used a quasi-experimental difference-in-differences design to study the quarterly prevalence of schizophrenia among US long-stay NH residents aged 65 years and older, by Black race and ADRD status. Using 2011-2015 Minimum Data Set 3.0 assessments, our analysis controlled for age, sex, measures of function and frailty (activities of daily living [ADL] and Changes in Health, End-stage disease and Symptoms and Signs scores) and behavioral expressions.

RESULTS

There were over 1.2 million older long-stay NH residents, annually. Schizophrenia diagnoses were highest among residents with ADRD. Among residents without ADRD, Black residents had higher rates of schizophrenia diagnoses compared to their nonblack counterparts prior to the partnership. Following the partnership, Black residents with ADRD had a significant increase of 1.7% in schizophrenia as compared to nonblack residents with ADRD who had a decrease of 1.7% (p = 0.007).

CONCLUSIONS

Following the partnership, Black NH residents with ADRD were more likely to have a schizophrenia diagnosis documented on their MDS assessments, and schizophrenia rates increased for Black NH residents with ADRD only. Further work is needed to examine the impact of "colorblind" policies such as the partnership and to determine if schizophrenia diagnoses are appropriately applied in NH practice, particularly for black Americans with ADRD.

Gender Disparities in Anti-dementia Medication Use among Older Adults: Health Equity Considerations and Management of Alzheimer's Disease and Related Dementias

Objective: The prevalence of Alzheimer's disease and related dementias (ADRD) in women is higher than men. However, the knowledge of gender disparity in ADRD treatment is limited. Therefore, this study aimed to determine the gender disparities in the receipt of anti-dementia medications among Medicare beneficiaries with ADRD in the U.S. Methods: We used data from the Medicare Current Beneficiary Survey 2016. Anti-dementia medications included cholinesterase inhibitors (ChEIs; including rivastigmine, donepezil, and galantamine) and N-methyl-D-aspartate (NMDA) receptor antagonists (including memantine). Descriptive analysis and multivariate logistic regression models were implemented to determine the possible gender disparities in the receipt of anti-dementia medications. Subgroup analyses were conducted to identify gender disparities among beneficiaries with Alzheimer's disease (AD) and those with only AD-related dementias. Results: Descriptive analyses showed there were statistically significant differences in age, marital status, and Charlson comorbidities index (CCI) between Medicare beneficiaries who received and who did not receive anti-dementia medications. After controlling for covariates, we found that female Medicare beneficiaries with ADRD were 1.7 times more likely to receive anti-dementia medications compared to their male counterparts (odds ratio [OR]: 1.71; 95% confidence interval [CI]: 1.19-2.45). Specifically, among Medicare beneficiaries with AD, females were 1.2 times more likely to receive anti-dementia medications (Odds Radio: 1.20; 95% confidence interval: 0.58-2.47), and among the Medicare beneficiaries with only AD-related dementias, females were 1.9 times more likely to receive anti-dementia medications (OR: 1.90; 95% CI: 1.23-2.95). Conclusion: Healthcare providers should be aware of gender disparities in receiving anti-dementia medications among patients with ADRD, and the need to plan programs of care to support both women and men. Future approaches to finding barriers of prescribing, receiving and, adhering to anti-dementia medications by gender should include differences in longevity, biology, cognition, social roles, and environment.

The Internet-Based Conversational Engagement Clinical Trial (I-CONECT) in Socially Isolated Adults 75+ Years Old: Randomized Controlled Trial Protocol and COVID-19 Related Study Modifications

Background: Increasing social interactions through communication technologies could offer a cost-effective prevention approach that slows cognitive decline and delays the onset of Alzheimer's disease. This paper describes the protocol of an active project named "Internet-based conversational engagement clinical trial (I-CONECT)" (ClinicalTrials.gov: NCT02871921). The COVID-19 pandemic related protocol modifications are also addressed in the current paper. Methods: I-CONECT is a multi-site, assessor-blind, randomized controlled behavioral intervention trial (RCT). We aim to randomize 320 socially isolated adults 75+ years old [160 Caucasian and 160 African American participants, 50:50 split between those with normal cognition and mild cognitive impairment (MCI)] recruited from the community to either the video chat intervention group or the control group (1:1 allocation). Those in the video chat group receive a computer and Internet service for the duration of the study, which they use to video chat with study staff for 30 min/day 4×/week for 6 months (high dose), and then 2×/week for an additional 6 months (maintenance dose). Both video chat and control groups have a brief (about 10 min) telephone check-in with study staff once per week. The primary outcome is the change in global cognitive function measured by Montreal Cognitive Assessment (MoCA) from baseline to 6 months. Secondary outcomes include changes in cognition in memory and executive function domains, emotional well-being measured by NIH Toolbox emotional battery, and daily functional abilities assessed with the Revised Observed Tasks of Daily Living (OTDL-R). Eligible participants have MRIs at baseline and 6 months. Participants contribute saliva for genetic testing (optional consent), and all video chats, weekly check-in calls and neuropsychological assessment sessions are recorded for speech and language analysis. The pandemic halted research activities and resulted in protocol modifications, including replacing in-person assessment with remote assessment, remote deployment of study equipment, and revised targeted sample size. Discussion: This trial provides user-friendly hardware for the conversational-based intervention that can be easily provided at participants' homes. The trial aspires to use age and culture-specific conversational materials and a related platform developed in this trial for enhancing cognitive reserve and improving cognitive function.

Longitudinal Comparison of Stability and Sensitivity in Quality of Life Scores Among Nursing Home Residents With and Without Diagnoses of Alzheimer's Disease and Related Dementias

BACKGROUND AND OBJECTIVES

Prevalence of nursing home residents with Alzheimer's disease and related dementias (ADRD) has increased along with a growing consensus that person-centered ADRD care in nursing homes should maximize quality of life (QoL). However, concerns about whether residents with ADRD can make appropriate QoL judgments persist. This study assesses the stability and sensitivity of a self-reported, multidomain well-being QoL measure for nursing home residents with and without ADRD.

RESEARCH DESIGN AND METHODS

This study linked the 2012-2015 Minnesota Nursing Home Resident QoL and Satisfaction with Care Survey, Minimum Data Set 3.0 (nursing home assessments), and Minnesota Department of Human Services Cost Reports. The QoL survey included cohort-resident pairs who participated for 2 consecutive years (N = 12 949; 8 803 unique residents from 2012-2013, 2013-2014, and 2014-2015 cohorts). Change in QoL between 2 years was conceptualized as stable when within 1.5 SD of the sample average. We used linear probability models to estimate associations of ADRD/Cognitive Function Scale status with the stability of QoL summary and domain scores (eg, social engagement) and the absolute change in QoL summary score, controlling for resident and facility characteristics.

RESULTS

Most (86.82%) residents had stable QoL summary scores. Residents with moderate to severe cognitive impairment, irrespective of ADRD, were less likely to have stable summary scores than cognitively capable residents without ADRD (p < .001), but associations varied by QoL domains. Among those with stable summary QoL scores, changes in health/functional status were associated with absolute changes in summary QoL score (p < .001), suggesting sensitivity of the QoL measure.

DISCUSSION AND IMPLICATIONS

QoL scores were similarly stable over time for most residents with and without ADRD diagnoses and were sensitive to changes in health/functional status. This self-reported QoL measure may be appropriate for nursing home residents, regardless of ADRD diagnosis, and can efficaciously be recommended to other states.

Rural-urban differences in diagnostic incidence and prevalence of Alzheimer's disease and related dementias

INTRODUCTION

Understanding rural-urban variation in the diagnostic incidence and prevalence of Alzheimer's disease and related dementias (ADRD) will inform policies to improve timely diagnosis and access to supportive services for older adults in rural communities.

METHODS

Using 2008 to 2015 national claims data for fee-for-service Medicare beneficiaries (roughly 170 million person-years), we computed unadjusted and adjusted diagnostic incidence and prevalence estimates for ADRD in metropolitan, micropolitan, and rural counties, and examined differences in survival rates.

RESULTS

Risk-adjusted ADRD diagnostic incidence was higher in rural versus metropolitan counties despite lower prevalence. Among beneficiaries diagnosed with ADRD in 2008, metropolitan county residents experienced longer survival compared to residents in rural and micropolitan counties.

DISCUSSION

These data suggest that older adults in rural communities may be underdiagnosed with ADRD, and/or diagnosed at later stages of dementia. Further work is needed to develop strategies to reduce this disparity.

Uncontrolled Pain and Risk for Depression and Behavioral Symptoms in Residents With Dementia

OBJECTIVES

Limited cohort studies have assessed the association between uncontrolled pain and risk for behavioral and psychological symptoms of dementia (BPSDs). We conducted a longitudinal cohort study to examine whether associations exist between uncontrolled pain and risk for 2 common BPSDs-depression and behavioral symptoms-among long-term care (LTC) residents with Alzheimer disease and related dementia (ADRD).

DESIGN

This retrospective cohort study analyzed quarterly data from the 5% Medicare sample linked to Minimum Data Set (MDS) 3.0 between January 1, 2011, and December 31, 2015.

SETTING AND PARTICIPANTS

LTC residents aged 50 years or older with ADRD who had chronic pain and at least 2 quarterly MDS 3.0 assessments.

METHODS

LTC residents were followed up quarterly from first observed quarterly MDS 3.0 until first outcome event or last observed quarterly MDS 3.0. Uncontrolled pain was defined as numerical rating scale >4, verbal descriptor scale of moderate or severe pain, or ≥1 pain indicators on the Checklist of Nonverbal Pain Indicators. Depression was defined as ≥10 on the Patient Health Questionnaire 9; behavioral symptoms were defined as the presence of psychotic (delusions or hallucinations) or disruptive behaviors (rejection of care, or physical, verbal, or other aggressive behaviors). Generalized linear models (GLMs) with marginal structural modeling (MSM) stabilized weights were used to examine uncontrolled pain and outcome risk.

RESULTS

The incidence rate of depression and behavioral symptoms during follow-up was 9.4 and 23.1 per 100 resident-years, respectively. Results from the MSM-GLMs showed that LTC residents with uncontrolled pain had a higher risk than those with controlled pain for developing depression [hazard ratio 1.67, 95% confidence interval (CI) 1.54-1.81] and behavioral symptoms (hazard ratio 1.28, 95% CI 1.19-1.37).

CONCLUSIONS AND IMPLICATIONS

Uncontrolled pain was associated with elevated risk for depressive and behavioral symptoms in dementia, underscoring the importance of pain assessment and control among LTC residents with ADRD.

Incidence of Homelessness among Veterans Newly Diagnosed with Alzheimer's Disease and Related Dementias

BACKGROUND

To determine the incidence of homelessness among Veterans diagnosed with Alzheimer's disease and related dementias (ADRD).

METHODS

We used Veterans Affairs (VA) administrative records to identify Veterans with a new ADRD diagnosis anytime between 2010-2019. Among these Veterans, we calculated the incidence of homelessness, and estimated the association between demographics, comorbidities and hazard of homelessness.

RESULTS

The incidence rate of homelessness was highest for Veterans diagnosed with ADRD between 18-49 years of age (14.9 per 1,000 person-years; 95%CI: 13.6, 16.3) and lowest for Veterans diagnosed with ADRD at 90+ years (0.3 per 1,000 person-years; 95%CI: 0.2, 0.4). The adjusted hazard ratio of homelessness was higher for unmarried Veterans, and those with alcohol use disorder, substance use disorder, liver disease, depression, hypertension, lung disease, post-traumatic stress disorder and psychoses.

CONCLUSIONS

Younger age and being unmarried at the time of ADRD diagnosis are associated with a greater risk of experiencing homelessness.

Successful Discharge to Community Gap of FFS Medicare Beneficiaries With and Without ADRD Narrowed

BACKGROUND/OBJECTIVES

We sought to compare the post-acute and long-term care experience of Medicare beneficiaries with and without Alzheimer Disease and Related Dementias (ADRD), and whether differences changed from January 1, 2007 to September 30, 2015.

DESIGN

Retrospective cross-sectional trend study using Medicare claims linked to the Centers for Medicare & Medicaid Services' (CMS) Minimum Data Set.

SETTING

CMS-certified skilled nursing facilities (skilled nursing facility (SNF), n = 17,043).

PARTICIPANTS

Fee-for-service Medicare beneficiaries aged ≥66 years (n = 6,614,939) discharged from a hospital to a SNF who had not lived in a nursing home during the year before hospitalization.

MEASUREMENTS

ADRD was defined by the Chronic Condition Data Warehouse. Outcome measures included: (1) successful discharge defined as being in SNF less than 90 days, then discharged back to the community, alive without subsequent inpatient health care for 30 continuous days; (2) became long-stay resident in SNF; (3) death in SNF within 90 days; (4) hospital readmission within 30 days of entering SNF; and (5) transferred to another nursing home within 30 days of entering SNF.

RESULTS

Successful discharge of beneficiaries with ADRD increased from 43.4% in 2007 to 53.9% in 2015 (average annual percent change (AAPC) = 2.1 (95% CI = 2.0-2.2)); those without ADRD also increased (from 59.1% to 63.6%, AAPC = 0.9 (95% CI = 0.7-1.1)) but not as fast as those with ADRD (P < .01). The proportion of all beneficiaries who became long-stay or were readmitted to the hospital decreased (P < .05). The proportion with ADRD who became long-stay was nearly three times higher than those without throughout the study (15.0% vs 5.5% in 2007; 11.3% vs 4.3% in 2015).

CONCLUSION

Though disparity in ADRD in becoming long-stay residents remains, the increase in successful discharges among those with ADRD also stresses the increasing importance of community as a care setting for adults with ADRD.

Racial disparity in end-of-life hospitalizations among nursing home residents with dementia

OBJECTIVE

Explore within and across nursing home (NH) racial disparities in end-of-life (EOL) hospitalizations for residents with Alzheimer's disease or related dementia (ADRD), and examine whether severe cognitive impairment influences these relationships.

DESIGN

Observational study merging, at the individual level, C2014-2017 national-level Minimum Data Set (MDS), Medicare Beneficiary Summary Files (MBSF), and Medicare Provider Analysis and Review (MedPAR). Nursing Home Compare (NHC) was also used.

SETTING

Long-stay residents who died in a NH or a hospital within 8 days of discharge.

PARTICIPANTS

Analytical sample included 665,033 decedent residents with ADRD in 14,595 facilities.

MAIN OUTCOMES AND MEASURES

The outcome was hospitalization within 30 days of death. Key independent variables were race, severe cognitive impairment, and NH-level proportion of black residents. Other covariates included socio-demographics, dual eligibility, hospice enrollment, and chronic conditions. Facility-level characteristics were also included (e.g. profit status, staffing hours, etc.). We fit linear probability models with robust standard errors, fixed and random effects.

RESULTS

Compared to whites, black decedents had a significantly (p < 0.01) higher risk of EOL hospitalizations (7.88%). Among those with severe cognitive impairment, whites showed a lower risk of hospitalizations (6.04%). But EOL hospitalization risk among blacks with severe cognitive impairment was still significantly elevated (β = 0.0494; p < 0.01). A comparison of the base model with the fixed and random-effects models showed statistically significant hospitalization risk by decedent's race both within and across facilities.

CONCLUSIONS AND RELEVANCE

We found disparities between black and white residents with ADRD both within and across facilities. The within-facility disparities may be due to residents' preferences and/or NH practices that contribute to differential treatment. The across facility differences point to the overall quality of care disparities in homes with a higher prevalence of black residents. Persistence of such systemic disparities among the most vulnerable individuals is extremely troubling.

The Institute on Methods and Protocols for Advancement of Clinical Trials in ADRD (IMPACT-AD): A Novel Clinical Trials Training Program

BACKGROUND

Alzheimer's Disease and Related Dementias (ADRD) clinical trials require multidisciplinary expertise in medicine, biostatistics, trial design, biomarkers, ethics, and informatics.

OBJECTIVES

To provide focused interactive training in ADRD clinical trials to a diverse cadre of investigators.

DESIGN

The Institute on Methods and Protocols for Advancement of Clinical Trials in ADRD (IMPACT-AD) is a novel multidisciplinary clinical trial training program funded by the National Institute on Aging and the Alzheimer's Association with two educational tracks. The Professionals track includes individuals who fill a broad variety of roles including clinicians, study coordinators, psychometricians, and other study professionals who wish to further their knowledge and advance their careers in ADRD trials. The Fellowship track includes current and future principal investigators and focuses on the design, conduct and analysis of ADRD clinical trials.

SETTING

The 2020 inaugural iteration of IMPACT-AD was held via Zoom.

PARTICIPANTS

Thirty-five trainees (15 Fellowship track; 20 Professionals track) were selected from 104 applications (34% acceptance rate). Most (n=25, 71%) identified as female. Fifteen (43%) were of a non-white race; six (18%) were of Hispanic ethnicity; eight (23%) indicated they were the first person in their family to attend college.

MEASUREMENTS

Participants completed daily evaluations as well as pre- and post-course assessments of learning.

RESULTS

Across topic areas, >90% of trainees evaluated their change in knowledge based on the lectures as "very much" or "somewhat increased." The mean proportion correct responses in pre- and post-course assessments increased from 55% to 75% for the Professionals track and from 54% to 78% for the Fellowship track.

CONCLUSIONS

IMPACT-AD successfully launched a new training opportunity amid a global pandemic that preliminarily achieved the goals of attracting a diverse cohort and providing meaningful training. The course is funded through 2025.

Home-Based Care for People with Alzheimer's Disease and Related Dementias (ADRD) during COVID-19 Pandemic: From Challenges to Solutions

There has been supporting evidence that older adults with underlying health conditions form the majority of the fatal cases in the current novel coronavirus disease (COVID-19) pandemic. While the impact of COVID-19 is affecting the general public, it is clear that these distressful experiences will be magnified in older adults, particularly people living with Alzheimer's disease and related dementia (ADRD), making them the most vulnerable group during this time. People with differing degrees of ADRD are especially susceptible to the virus, not only because of their difficulties in assessing the threat or remembering the safety measures, but also because of the likelihood to be subject to other risk factors, such as lack of proper care and psychological issues. Therefore, in this article, we will discuss the challenges related to home-based care for people with ADRD during a pandemic and propose a formulation of systematic solutions to address these challenges and to alleviate the social and economic impact resulting from the crisis.

Incremental Health Care Expenditures of the Spouses of Older Adults With Alzheimer's Diseases and Related Dementias (ADRD)

OBJECTIVE

Previous research has found that having a spouse with Alzheimer's disease and related dementias (ADRD) is associated with higher health care expenditures, however it is unclear if this difference remains after accounting for the demographics and health status of the non-ADRD spouse. This paper aims to estimate the adjusted incremental health care expenditures of having a spouse with ADRD.

DESIGN

Cross-sectional study of publicly available survey data (2003-2017 Medical Expenditure Panel Survey).

SETTING

Representative sample of U.S. households.

PARTICIPANTS

Community-dwelling and married older adults (n = 28,356).

MEASUREMENT

Two-part models and recycled prediction techniques to estimate the incremental effects of having a spouse with ADRD on annual health care expenditures, while adjusting for demographics, socioeconomic characteristics, and health conditions.

RESULTS

Spouses of older adults with ADRD were older, had worse perceived mental health, and had greater difficulties with activities of daily living, compared to older adults with cognitively normal spouses. Spouses of ADRD patients had significantly higher unadjusted total health care expenditures, however their adjusted incremental expenditure was not significantly greater. After controlling for demographics and health status, ADRD spouses had significantly higher home health care expenditures, but significantly lower outpatient expenditures.

CONCLUSION

Results suggested that the higher health care expenditures in older adults with ADRD spouses can be attributed to the higher rate of comorbidities, rate of functional limitations, and mean age in this group. The increased use of home health and decreased use of outpatient in this population suggests the importance of tailoring preventative health care and social services to meet the needs of this group.

Non-Cancer Chronic Pain Conditions and Risk for Incident Alzheimer's Disease and Related Dementias in Community-Dwelling Older Adults: A Population-Based Retrospective Cohort Study of United States Medicare Beneficiaries, 2001-2013

Accumulating evidence suggests that certain chronic pain conditions may increase risk for incident Alzheimer's disease and related dementias (ADRD). Rigorous longitudinal research remains relatively sparse, and the relation of overall chronic pain condition burden to ADRD risk remains little studied, as has the potential mediating role of sleep and mood disorders. In this retrospective cohort study, we investigated the association of common non-cancer chronic pain conditions (NCPC) at baseline to subsequent risk for incident ADRD, and assessed the potential mediating effects of mood and sleep disorders, using baseline and 2-year follow-up data using 11 pooled cohorts (2001-2013) drawn from the U.S. Medicare Current Beneficiaries Survey (MCBS). The study sample comprised 16,934 community-dwelling adults aged ≥65 and ADRD-free at baseline. NCPC included: headache, osteoarthritis, joint pain, back or neck pain, and neuropathic pain, ascertained using claims data; incident ADRD (N = 1149) was identified using claims and survey data. NCPC at baseline remained associated with incident ADRD after adjustment for sociodemographics, lifestyle characteristics, medical history, medications, and other factors (adjusted odds ratio (AOR) for any vs. no NCPC = 1.21, 95% confidence interval (CI) = 1.04-1.40; p = 0.003); the strength and magnitude of this association rose significantly with increasing number of diagnosed NCPCs (AOR for 4+ vs. 0 conditions = 1.91, CI = 1.31-2.80, p-trend < 0.00001). Inclusion of sleep disorders and/or depression/anxiety modestly reduced these risk estimates. Sensitivity analyses yielded similar findings. NCPC was significantly and positively associated with incident ADRD; this association may be partially mediated by mood and sleep disorders. Additional prospective studies with longer-term follow-up are warranted to confirm and extend our findings.

Light, sleep and circadian rhythms in older adults with Alzheimer's disease and related dementias

Alzheimer's disease and related dementias (ADRD) can cause sleep and behavioral problems that are problematic for ADRD patients and their family caregivers. Light therapy has shown promise as a nonpharmacological treatment, and preliminary studies demonstrate that timed light exposure can consolidate and improve nighttime sleep efficiency, increase daytime wakefulness and reduce evening agitation without the adverse effects of pharmacological solutions. Compliance with light treatment and the accurate measurement of light exposures during treatment, however, have presented barriers for the adoption of light therapy for ADRD. Recent research showing that the circadian system is maximally sensitive to short-wavelength light opens the way for the potential application of lower, more-targeted light intensities to maximize compliance and individualize light dose/timing in therapeutic settings.