Specialist Availability and Drug Adherence in Older Adults with Dementia Across Regions of the United States.

BACKGROUND: Access to specialists facilitates appropriate Alzheimer's disease and related dementia (ADRD) medication use and adherence. However, there is little information on the impact of specialists' availability on ADRD medication adherence, especially in regions of the United States (US) where specialists are scarce, e.g., the Deep South (DS). OBJECTIVE: To ascertain whether the availability of specialty physicians in the DS and other US regions predicts ADRD medication adherence among community-dwelling older adultsMethods:We conducted secondary analyses of claims data for 54,194 Medicare beneficiaries with ADRD in 2013-2015. Medication adherence was measured using the proportion of days covered (PDC). Multivariable-adjusted Modified Poisson regression was used to examine associations of adherence with physicians' availability by region. RESULTS: The race/ethnicity distribution was 81.44% white, 9.17% black, 6.24% Hispanic, 2.25% Asian, and 1% other; 71.81% were female, and 42.36% were older than 85 years. Beneficiaries across regions differed in all individual and contextual characteristics except sex and comorbidities. Neurologists and psychiatrists' availability was not significantly associated with adherence (DS = 1.00, 0.97-1.03 & non-DS = 1.01, 1.00-1.01). Race and having ≥1 specialist visits were associated with a lower risk of adherence in both regions (p < 0.0001). Advanced age, dual Medicare/Medicaid eligibility, and living in non-large metropolitan areas, were associated with adherence in the non-DS region. CONCLUSION: Among older Americans with ADRD, a context defined by specialist availability does not affect adherence, but other context characteristics related to socioeconomic status may. Research should further examine the influence of individual and contextual factors on ADRD treatment among older adults.

Dementia Care in Diverse Older Adults in the U.S. Deep South and the Rest of the United States.

BACKGROUND: Use of specialists and recommended drugs has beneficial effects for older adults living with Alzheimer's disease and related dementia (ADRD). Gaps in care may exist for minorities, e.g., Blacks, and especially in the United States (U.S.) Deep South (DS), a poor U.S. region with rising ADRD cases and minority overrepresentation. Currently, we have little understanding of ADRD care utilization in diverse populations in this region and elsewhere in the U.S. (non-DS), and the factors that adversely impact it. OBJECTIVE: To examine utilization of specialists and ADRD drugs (outcomes) in racial/ethnic groups of older adults with ADRD and the personal or context-level factors affecting these outcomes in DS and non-DS. METHODS: We obtained outcomes and personal-level covariates from claims for 127,512 Medicare beneficiaries with ADRD in 2013-2015, and combined county-level data in exploratory factor analysis to define context-level covariates. Adjusted analyses tested significant association of outcomes with Black/White race and other factors in DS and non-DS. RESULTS: Across racial/ethnic groups, 33%-43% in DS and 43%-50% in non-DS used specialists; 47%-55% in DS and 41%-48% in non-DS used ADRD drugs. In adjusted analyses, differences between Blacks and Whites were not significant. Vascular dementia, comorbidities, poverty, and context-level factor "Availability of Medical Resources" were associated with specialist use; Alzheimer's disease and senile dementia, comorbidities, and specialist use were associated with drug use. In non-DS only, other individual, context-level covariates were associated with the outcomes. CONCLUSION: We did not observe significant gaps in ADRD care in DS and non-DS; however, research should further examine determinants of low specialist and drug use in these regions.

Cognitive Processing Speed Is Strongly Related to Driving Skills, Financial Abilities, and Other Instrumental Activities of Daily Living in Persons With Mild Cognitive Impairment and Mild Dementia.

BACKGROUND: Cognitive processing speed is important for performing everyday activities in persons with mild cognitive impairment (MCI). However, its role in daily function has not been examined while simultaneously accounting for contributions of Alzheimer's disease (AD) risk biomarkers. We examine the relationships of processing speed and genetic and neuroimaging biomarkers to composites of daily function, mobility, and driving. METHOD: We used baseline data from 103 participants on the MCI/mild dementia spectrum from the Applying Programs to Preserve Skills trial. Linear regression models examined relationships of processing speed, structural magnetic resonance imaging (MRI), and genetic risk alleles for AD to composites of performance-based instrumental activities of daily living (IADLs), community mobility, and on-road driving evaluations. RESULTS: In multivariable models, processing speed and the brain MRI neurodegeneration biomarker Spatial Pattern of Abnormality for Recognition of Early Alzheimer's disease (SPARE-AD) were significantly associated with functional and mobility composite performance. Better processing speed and younger age were associated with on-road driving ratings. Genetic risk markers, left hippocampal atrophy, and white matter lesion volumes were not significant correlates of these abilities. Processing speed had a strong positive association with IADL function (p < .001), mobility (p < .001), and driving (p = .002). CONCLUSIONS: Cognitive processing speed is strongly and consistently associated with critical daily functions in persons with MCI in models including genetic and neuroimaging biomarkers of AD risk. SPARE-AD scores also significantly correlate with IADL performance and mobility. Results highlight the central role of processing speed in everyday task performance among persons with MCI/mild dementia.

Qualitative assessment of self-identity in people with advanced dementia.

This study aimed to understand the preserved elements of self-identity in persons with moderate to severe dementia attributable to Alzheimer's disease. A semi-structured interview was developed to explore the narrative self among residents with dementia in a residential care facility, and residents without dementia in an independent living setting. The interviews were transcribed verbatim from audio recordings and analyzed for common themes, while being sensitive to possible differences between the groups. The participants with dementia showed evidence of self-reference even though losses in explicit memory were evident. The most noticeable difference between the two groups was time frame reference. Nonetheless, all participants showed understanding of their role in relationships and exhibited concrete preferences. Our findings suggest that memory loss and other cognitive deficits associated with moderate to severe dementia do not necessarily lead to a loss of "self."

Implications of early treatment among Medicaid patients with Alzheimer's disease.

OBJECTIVE: The objective of this study was to examine the effect of treatment timing on risk of institutionalization of Medicaid patients with Alzheimer's disease (AD) and to estimate the economic implications of earlier diagnosis and treatment initiation. METHODS: New Jersey Medicaid claims data (1997-2009) were used retrospectively to study the effect of treatment on time to institutionalization. Observed Medicaid payments were used to calculate savings from delayed institutionalization, adjusting for cost offsets resulting from concurrent changes in use of other medical services. RESULTS: Initiation of existing therapies at earliest symptomatic onset is predicted to delay institutionalization by 91 days, reducing Medicaid costs by $19,108/institutionalized patient. Incorporating an 18.5% cost offset from increased use of other medical services as well as drug costs associated with earlier treatment results in net savings of $12,687/patient. Projected annual Medicaid savings exceed $1 billion. CONCLUSION: Earlier treatment leads to a small delay in institutionalization among AD patients, resulting in significant costs savings to Medicaid.

Pre-diagnosis excess acute care costs in Alzheimer's patients among a US Medicaid population.

BACKGROUND AND OBJECTIVES: Prior research has documented that Alzheimer's disease (AD) is associated with increased costs from comorbid conditions. However, little is known about medical resource utilization and costs among AD patients prior to the onset of cognitive symptoms. This study estimates excess acute care costs among Medicaid AD patients in the year prior to diagnosis. STUDY DESIGN: Administrative claims data for New Jersey Medicaid patients over the period 1997-2010 were retrospectively analyzed. The study focused on non-institutionalized AD patients and examined their medical costs compared with matched controls with no dementia over the 12 months prior to their preliminary diagnosis. Costs reflect amounts reimbursed by Medicaid to medical service providers, reported in 2010 US dollars. RESULTS: The study sample included 11,536 AD patients who were matched to controls. Average age was 76 years, and 76.2 % were female. Compared with matched controls, total medical costs over the 12-month pre-index period were US$ 5,549 higher among AD patients (US$ 14,977 vs. US$ 9,428, p < 0.001), of which US$ 3,321 (p < 0.001) was due to outpatient services. Home care and medical daycare services accounted for US $1,442 (p < 0.001) of the difference. Emergency department visits and inpatient care accounted for only a small fraction of the excess costs. CONCLUSIONS: Compared with controls, Medicaid AD patients incurred higher acute care costs in the 12 months prior to their preliminary diagnosis, suggesting room for beneficial interventions and better disease management should earlier diagnosis become possible. These findings may be especially relevant in light of new criteria facilitating earlier diagnosis of AD.

Cost-effectiveness of drug therapies for Alzheimer's disease: A brief review.

Alzheimer's disease (AD) is an important and rapidly expanding public health problem. Its large economic burden is a result of its disabling nature, chronicity, and high prevalence in older segments of the population. Current treatments of AD have been criticized for providing insufficient benefit to justify their costs, but variability in assessing both costs and benefits make evaluation of the existing data problematic. Inclusion of the value of caregiver time is a major driver of the determination of cost-effectiveness. Population-based studies and those based on application of economic models to other study outcomes tend to identify greater cost-effectiveness than prospectively collected data. Differences in healthcare economics across countries also limit generalization of specific study findings. The current state of evidence suggests that treatment decisions in AD should be based on assessment of benefit in individual patients rather than broader societal economic factors.

The cost benefit to health plans of pharmacotherapy for Alzheimer's disease.

Treatment of Alzheimer's disease (AD) is a major public health issue, with the potential for significant impact on MCOs. As the number of people affected with AD continues to rise, the importance of this problem will grow as well. This article reviews patient and caregiver outcomes associated with reduced health care costs and their implications for MCOs. Cholinesterase inhibitors (ChEIs) are effective in treating cognitive, functional, and behavioral symptoms for patients with mild to moderate and moderate to severe AD. Treatment with memantine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has been shown to benefit patients with moderate to severe AD. Pharmacoeconomic studies indicate that donepezil and memantine treatment may reduce total costs of care for AD patients and their caregivers, with potential economic benefits to MCOs.

Optimizing coding and reimbursement to improve management of Alzheimer's disease and related dementias.

The objectives of this study were to review the diagnostic, International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM), diagnosis related groups (DRGs), and common procedural terminology (CPT) coding and reimbursement issues (including Medicare Part B reimbursement for physicians) encountered in caring for patients with Alzheimer's disease and related dementias (ADRD); to review the implications of these policies for the long-term clinical management of the patient with ADRD; and to provide recommendations for promoting appropriate recognition and reimbursement for clinical services provided to ADRD patients. Relevant English-language articles identified from MEDLINE about ADRD prevalence estimates; disease morbidity and mortality; diagnostic coding practices for ADRD; and Medicare, Medicaid, and managed care organization data on diagnostic coding and reimbursement were reviewed. Alzheimer's disease (AD) is grossly undercoded. Few AD cases are recognized at an early stage. Only 13% of a group of patients receiving the AD therapy donepezil had AD as the primary diagnosis, and AD is rarely included as a primary or secondary DRG diagnosis when the condition precipitating admission to the hospital is caused by AD. In addition, AD is often not mentioned on death certificates, although it may be the proximate cause of death. There is only one ICD-9-CM code for AD-331.0-and no clinical modification codes, despite numerous complications that can be directly attributed to AD. Medicare carriers consider ICD-9 codes for senile dementia (290 series) to be mental health codes and pay them at a lower rate than medical codes. DRG coding is biased against recognition of ADRD as an acute, admitting diagnosis. The CPT code system is an impediment to quality of care for ADRD patients because the complex, time-intensive services ADRD patients require are not adequately, if at all, reimbursed. Also, physicians treating significant numbers of AD patients are at greater risk of audit if they submit a high frequency of complex codes. AD is grossly undercoded in acute hospital and outpatient care settings because of failure to diagnose, limitations of the coding system, and reimbursement issues. Such undercoding leads to a lack of recognition of the effect of AD and its complications on clinical care and impedes the development of better care management. We recommend continuing physician education on the importance of early diagnosis and care management of AD and its documentation through appropriate coding, expansion of the current ICD-9-CM codes for AD, more appropriate use of DRG coding for ADRD, recognition of the need for time-intensive services by ADRD patients that result in a higher frequency of use of complex CPT codes, and reimbursement for CPT codes that cover ADRD care management services.

Cost-effective recognition and diagnosis of dementia.

Alzheimer's disease (AD) has the potential to become the most overwhelming public health concern of this century due to increasing life expectancy and growth in the aging population. As a result, primary care physicians and neurologists will be seeing a greater number of elderly patients in their practice and will subsequently be expected to both identify and initiate treatment in those individuals who may display signs of dementia and related neurologic conditions. There is good evidence that AD is underrecognized or undercoded in primary care settings. Underrecognition is an important problem in this population because early treatment and counseling have been shown to provide benefits to both patients and caregivers. As their patient population ages, physicians need to learn to recognize the early symptoms of AD and make a diagnosis in order to provide cost-effective therapies.