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Authors: Hill, Jerrold | Fillit, Howard | Shah, Sonali N. | del Valle, Megan C. | Futterman, Robert

Article Type: Research Article

Abstract: Background: While vascular dementia (VaD) is the second most prevalent dementia diagnosis, little is known about healthcare use and costs for VaD. Purpose: This study compares the healthcare use and costs of community-dwelling patients with VaD to patients with Alzheimer's disease (AD), other dementias (OD), cerebrovascular disease without dementia (CVD), and patients without dementia or cerebrovascular disease (controls). Methods: Using diagnoses codes from medical claims and encounter records, 678 VaD, 1,722 AD, 957 OD, 2,718 CVD, and 14,023 controls were identified from patients enrolled in a 100,000-member group practice Medicare HMO during 1999–2002. Annual healthcare use and costs of the …study groups were compared, using regression analysis to control for patient characteristics. Results: VaD patients had the highest annual costs, $14,387, followed by $10,716 for OD, $8,254 for CVD, and $7,839 for AD, and $5,494 for controls (p<0.0001 for all comparisons to VaD). Despite higher total direct costss, VaD patients had lower costs for physician visits and prescription drugs compared with all study groups except OD. In contrast, CVD patients had the highest costs for these services. Moreover, hospital admissions for VaD were nearly twice those for CVD, and hospital days for VaD nearly three times those for CVD, despite the high prevalence of cardiovascular conditions for both VaD and CVD. Conclusions: VaD patients had higher healthcare costs compared to all other patient groups. The substantially higher costs for VaD compared to CVD and the differences in use of healthcare services by VaD compared to CVD suggest that dementia, not cerebrovascular disease, is a major source of the cost differences. Lower costs for physician visits and prescription drugs for VaD suggest possible opportunities for improving ambulatory care and preventing high-cost hospitalizations. Show more

Keywords: Vascular dementia, healthcare cost, healthcare utilization, Alzheimer's disease

DOI: 10.3233/JAD-2005-8105

Citation: Journal of Alzheimer's Disease, vol. 8, no. 1, pp. 43-50, 2005

Authors: Robinson, Rebecca L. | Rentz, Dorene M. | Bruemmer, Valerie | Scott Andrews, Jeffrey | Zagar, Anthony | Kim, Yongin | Schwartz, Ronald L. | Ye, Wenyu | Fillit, Howard M.

Article Type: Research Article

Abstract: Background: Alzheimer’s disease (AD) is one of the costliest diseases in the United States. Objective: To describe aspects of real-world patient and caregiver burden in patients with clinician-diagnosed early AD, including mild cognitive impairment (MCI) and mild dementia (MILD) due to AD. Methods: Cross-sectional assessment of GERAS-US, a 36-month cohort study of patients seeking care for early AD. Eligible patients were categorized based on study-defined categories of MCI and MILD and by amyloid positivity [+] or negativity [–] within each severity cohort. Demographic characteristics, health-related outcomes, medical history, and caregiver burden by amyloid status are described. Results: Of 1,198 patients …with clinician-diagnosed early AD, 52% were amyloid[+]. For patients in both cohorts, amyloid[–] was more likely to occur in those with: delayed time to an AD-related diagnosis, higher rates of depression, poorer Bath Assessment of Subjective Quality of Life in Dementia scores, and Hispanic/Latino ethnicity (all p  < 0.05). MILD[–] patients (versus MILD[+]) were more medically complex with greater rates of depression (55.7% versus 40.4%), sleep disorders (34.3% versus 26.5%), and obstructive pulmonary disease (11.8% versus 6.6%); and higher caregiver burden (Zarit Burden Interview) (all p  < 0.05). MILD[+] patients had lower function according to the Functional Activities Questionnaire (p  < 0.001), yet self-assessment of cognitive complaints across multiple measures did not differ by amyloid status in either severity cohort. Conclusions: Considerable patient and caregiver burden was observed in patients seeking care for memory concerns. Different patterns emerged when both disease severity and amyloid status were evaluated underscoring the need for further diagnostic assessment and care for patients. Study Registry: H8A-US-B004; ClinicalTrials.gov: NCT02951598. Show more

Keywords: Alzheimer’s disease, amyloid, burden of illness, florbetapir F18, mild Alzheimer’s dementia, mild cognitive impairment

DOI: 10.3233/JAD-190430

Citation: Journal of Alzheimer's Disease, vol. 72, no. 1, pp. 279-292, 2019

Authors: Robinson, Rebecca L. | Rentz, Dorene M. | Andrews, Jeffrey Scott | Zagar, Anthony | Kim, Yongin | Bruemmer, Valerie | Schwartz, Ronald L. | Ye, Wenyu | Fillit, Howard M.

Article Type: Research Article

Abstract: Background: Costs associated with early stages of Alzheimer’s disease (AD; mild cognitive impairment [MCI] and mild dementia [MILD]) are understudied. Objective: To compare costs associated with MCI and MILD due to AD in the United States. Methods: Data included baseline patient/study partner medical history, healthcare resource utilization, and outcome assessments as part of a prospective cohort study. Direct, indirect, and total societal costs were derived by applying standardized unit costs to resources for the 1-month pre-baseline period (USD2017). Costs/month for MCI and MILD cohorts were compared using analysis of variance models. To strengthen the confidence of diagnosis, amyloid-β (Aβ ) …tests were included and analyses were replicated stratifying within each cohort by amyloid status [+ /−]. Results: Patients (N  = 1327) with MILD versus MCI had higher total societal costs/month ($4243 versus $2816; p  < 0.001). These costs were not significantly different within each severity cohort by amyloid status. The largest fraction of overall costs were informal caregiver costs (45.1%) for the MILD cohort, whereas direct medical patient costs were the largest for the MCI cohort (39.0%). Correspondingly, caregiver time spent on basic activities of daily living (ADLs), instrumental ADLs, and supervision time was twice as high for MILD versus MCI (all p  < 0.001). Conclusion: Early AD poses a financial burden, and despite higher functioning among those with MCI, caregivers were significantly impacted. The major cost driver was the patient’s clinical cognitive-functional status and not amyloid status. Differences were primarily due to rising need for caregiver support. Show more

Keywords: Amyloid, burden of illness, dementia, economic burden, florbetapir F18, mild cognitive impairment, societal burden, H8A-US-B004, NCT02951598

DOI: 10.3233/JAD-191212

Citation: Journal of Alzheimer's Disease, vol. 75, no. 2, pp. 437-450, 2020

Authors: Black, Christopher M. | Fillit, Howard | Xie, Lin | Hu, Xiaohan | Kariburyo, M. Furaha | Ambegaonkar, Baishali M. | Baser, Onur | Yuce, Huseyin | Khandker, Rezaul K.

Article Type: Research Article

Abstract: Background: Current information is scarce regarding comorbid conditions, treatment, survival, institutionalization, and health care utilization for Alzheimer’s disease (AD) patients. Objectives: Compare all-cause mortality, rate of institutionalization, and economic burden between treated and untreated newly-diagnosed AD patients. Methods: Patients aged 65–100 years with ≥1 primary or ≥2 secondary AD diagnoses (ICD-9-CM:331.0] with continuous medical and pharmacy benefits for ≥12 months pre-index and ≥6 months post-index date (first AD diagnosis date) were identified from Medicare fee-for-service claims 01JAN2011–30JUN2014. Patients with AD treatment claims or AD/AD-related dementia diagnosis during the pre-index period were excluded. Patients were assigned to treated and untreated cohorts …based on AD treatment received post-index date. Total 8,995 newly-diagnosed AD patients were identified; 4,037 (44.8%) were assigned to the treated cohort. Time-to-death and institutionalization were assessed using Cox regression. To compare health care costs and utilizations, 1 : 1 propensity score matching (PSM) was used. Results: Untreated patients were older (83.85 versus 81.44 years; p  < 0.0001), with more severe comorbidities (mean Charlson comorbidity index: 3.54 versus 3.22; p  < 0.0001). After covariate adjustment, treated patients were less likely to die (hazard ratio[HR] = 0.69; p  < 0.0001) and were associated with 20% lower risk of institutionalization (HR = 0.801; p  = 0.0003). After PSM, treated AD patients were less likely to have hospice visits (3.25% versus 9.45%; p  < 0.0001), and incurred lower annual all-cause costs ($25,828 versus $30,110; p  = 0.0162). Conclusion: After controlling for comorbidities, treated AD patients have better survival, lower institutionalization, and sometimes fewer resource utilizations, suggesting that treatment and improved care management could be beneficial for newly-diagnosed AD patients from economic and clinical perspectives. Show more

Keywords: Alzheimer’s disease, institutionalization, Medicare, mortality

DOI: 10.3233/JAD-170518

Citation: Journal of Alzheimer's Disease, vol. 61, no. 1, pp. 185-193, 2018

Authors: Aigbogun, Myrlene Sanon | Cloutier, Martin | Gauthier-Loiselle, Marjolaine | Guerin, Annie | Ladouceur, Martin | Baker, Ross A. | Grundman, Michael | Duffy, Ruth A. | Hartry, Ann | Gwin, Keva | Fillit, Howard

Article Type: Research Article

Abstract: Background: Few studies have examined patient characteristics and treatment patterns among patients with dementia and agitation in the United States (US). Objective: To examine real-world treatment patterns and characteristics of patients with agitation related to dementia who were treated with antipsychotics in US residential care and community-based settings. Methods: This retrospective chart review collected US physician-level data from patients 55 to 90 years old initiated on an antipsychotic medication for the treatment of agitation related to dementia from January 2018 to May 2018. Clinical characteristics and treatment patterns were assessed overall and stratified by residential care and community-based settings. Results: …A total of 313 participating physicians, 59.5% of whom were primary care physicians, abstracted 801 patient charts (residential care: n  = 312; community-based: n  = 489). Of patients with agitation who were initiated on an antipsychotic, most patients (74.5%) were initiated within 3 months of the onset of their studied agitation episode, and 62.8% experienced multiple agitation episodes before initiation. While non-pharmacological therapies are recommended first-line approach for agitation in dementia, use of non-pharmacological therapy before initiation of antipsychotics was reported for only 37.8% of patients in residential care and 21.3% in community-based settings. Conclusion: Most patients were initiated on an antipsychotic treatment after multiple episodes of agitation and largely without initial non-pharmacological therapy, suggesting that current treatment guideline recommendations for first-line non-pharmacological intervention may not be adequately followed in clinical practice. Understanding the clinical burden and treatment patterns among dementia patients with agitation is imperative for effective disease management. Show more

DOI: 10.3233/JAD-200127

Citation: Journal of Alzheimer's Disease, vol. 77, no. 3, pp. 1181-1194, 2020

Authors: Zhu, Yingying | Olchanski, Natalia | Cohen, Joshua T. | Freund, Karen M. | Faul, Jessica D. | Fillit, Howard M. | Neumann, Peter J. | Lin, Pei-Jung

Article Type: Research Article

Abstract: Background: Older adults with dementia including Alzheimer’s disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits. Objective: This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia. Methods: This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last …90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions. Results: Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42–2.35]; non-advanced dementia: OR = 1.16 [1.01–1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74–0.96]) and in nursing homes (OR = 0.68 [0.53–0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences. Conclusions: Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia. Show more

Keywords: Advance care planning, Alzheimer’s disease, end of life, life-sustaining treatments

DOI: 10.3233/JAD-230692

Citation: Journal of Alzheimer's Disease, vol. 96, no. 3, pp. 1183-1193, 2023

Authors: Andrieu, Sandrine | Coley, Nicola | Aisen, Paul | Carrillo, Maria C. | DeKosky, Steven | Durga, Jane | Fillit, Howard | Frisoni, Giovanni B. | Froelich, Lutz | Gauthier, Serge | Jones, Roy | Jönsson, Linus | Khachaturian, Zaven | Morris, John C. | Orgogozo, Jean-Marc | Ousset, Pierre-Jean | Robert, Philippe | Salmon, Eric | Sampaio, Cristina | Verhey, Frans | Wilcock, Gordon | Vellas, Bruno

Article Type: Review Article

Abstract: The prevention of neurodegenerative dementias, such as Alzheimer's disease, is a public health priority. Due to the large numbers of affected patients, even interventions bringing about a relatively small delay in disease onset could have large public health effects. Randomized controlled trials (RCTs) are required to demonstrate the effectiveness of preventive interventions, but such trials raise specific methodological questions because they are new in the field of neurodegenerative diseases, and require large numbers of elderly subjects and lengthy follow-up periods. We performed a literature search to identify primary prevention RCTs for neurodegenerative dementia. The methodology of the trials was summarized …and discussed during two expert meetings. Overall, 39 trials were identified that assessed dementia incidence or cognitive decline as a primary or secondary study outcome. Age was the most common selection criteria for target populations. Follow-up periods ranged from one month to nine years and were longest in studies measuring dementia incidence as an outcome. Results of RCTs have so far been generally negative and conflicting with those of observational studies, perhaps due to methodological issues. Future trials must therefore carefully consider the target population, outcomes and duration of follow-up to be used, and should assess the problem of attrition. Show more

Keywords: Alzheimer's disease, clinical trials, clinical trials methodology, cognitive aging, cognitive decline, dementia, prevention trials, study design

DOI: 10.3233/JAD-2009-0971

Citation: Journal of Alzheimer's Disease, vol. 16, no. 2, pp. 235-270, 2009