A real-world assessment of healthcare costs associated with agitation in Alzheimer's dementia.

AIMS: To describe and compare clinical characteristics, healthcare costs, and institutionalization/mortality outcomes among patients with and without agitation associated with Alzheimer's dementia (AAD). METHODS: Data from the Reliant Medical Group database (01/01/2016-03/31/2020) were used, including claims, electronic medical records, and clinical information/physician notes abstracted from medical charts. Patients aged ≥55 years with Alzheimer's dementia (AD) were observed during a randomly selected 12-month study period after AD diagnosis. Using information recorded in medical charts, patients were classified into cohorts based on experiencing (agitation cohort) and not experiencing (no agitation cohort) agitated behaviours during the study period. Entropy balancing was used to create reweighted cohorts with similar characteristics. Study outcomes (patient demographic and clinical characteristics, treatments received, healthcare costs, institutionalization and death events) were compared between cohorts; agitation characteristics were described for the agitation cohort only. RESULTS: Among 711 patients included in the study, 240 were classified in the agitation cohort and 471 in the no agitation cohort. After reweighting, several comorbidities were more frequently observed in the agitation versus no agitation cohort, including infection, depression, and altered mental status. Use of antidepressants, anticonvulsants, antipsychotics, and antianxiety medications was more common in the agitation versus no agitation cohort. Common agitated behaviours included hitting (20.8%), pacing/aimless wandering (17.5%), and cursing/verbal aggression (15.0%). Total all-cause healthcare costs were $4287 per-patient-per-year higher in the agitation cohort versus no agitation cohort (p = 0.04), driven by higher inpatient costs. Death was more common and time to death and institutionalization were shorter in the agitation versus no agitation cohort. LIMITATIONS: Results may not be generalizable to the US population with AD. CONCLUSIONS: Among patients with AD, agitation was associated with shorter time to death/institutionalization and increased comorbidities, medication use, and healthcare costs, highlighting the additional clinical and economic burden that agitation poses to patients and the healthcare system.

Development and assessment of a brief screening tool for psychosis in dementia.

INTRODUCTION: Hallucinations and delusions (H+D) are common in dementia, but screening for these symptoms-especially in busy clinical practices-is challenging. METHODS: Six subject matter experts developed the DRP3™ screen, a novel valid tool to detect H+D in dementia, assessed its content validity through alignment with DRP reference assessments (Scale for the Assessment of Positive Symptoms-Hallucinations + Delusions, Neuropsychiatric Inventory-Questionnaire, International Psychogeriatric Association Criteria), and retrospectively investigated its ability to detect H+D in HARMONY trial (NCT03325556) enrollees. RESULTS: All items from three reference assessments demonstrated significant agreement with the DRP3 screen among raters (P < .0001). Retrospectively applying the DRP3 screen to HARMONY identified all (N = 392) trial enrollees. DISCUSSION: The DRP3 screen, comprising three yes/no questions, is a content-valid tool for detecting H+D in dementia that aligned with current reference assessments and successfully identified trial participants when retrospectively applied to a completed trial. Within busy practice constraints, the DRP3 screen provides a brief tool for sensitive detection of H+D in patients with dementia.

Rapid Depression Assessment in Geriatric Patients.

Depression is common in geriatric patients, especially in those with multiple comorbidities and polypharmacy. Depression in older adults is often underdiagnosed and undertreated. Initial screening for depression can easily be accomplished in the waiting room. Yet the clinical interview still remains the gold standard for diagnosing geriatric depression. Key components of the clinical interview are observant watching of the patient for the subtle signs of depression. Clinical interview should be done with sensitivity to the importance of privacy. Illicit substances and medical conditions may significantly contribute. Suicide assessment should be done in a step wise manner.

A fixed-dose combination of memantine extended-release and donepezil in the treatment of moderate-to-severe Alzheimer's disease.

Currently available therapies for the treatment of Alzheimer's disease (AD) consist of cholinesterase inhibitors (ChEIs), such as donepezil, and the N-methyl-D-aspartate receptor antagonist memantine. In December 2014, the US Food and Drug Administration approved Namzaric™, a once-daily, fixed-dose combination (FDC) of memantine extended-release (ER) and donepezil for patients with moderate-to-severe AD. The FDC capsule is bioequivalent to the coadministered individual drugs, and its bioavailability is similar when taken fasting, with food, or sprinkled onto applesauce. The combination of memantine and ChEIs in moderate-to-severe AD provides additional benefits to ChEI monotherapy across multiple domains and may delay the time to nursing home admission. A dedicated study of memantine ER compared to placebo in patients on a stable dose of a ChEI found statistically significant benefits on cognition and global status but not functioning. Treatment with memantine ER and donepezil is generally well tolerated, although higher doses of ChEIs are associated with more serious adverse events such as vomiting, syncope, and weight loss. Potential advantages of the FDC include a simpler treatment regimen, reduction in pill burden, and the ability to sprinkle the capsule onto soft foods. Patients who may benefit from the FDC include those with significant dysphagia, a history of poor compliance, or limited caregiver interaction. However, available evidence that these advantages would increase treatment adherence and persistence is conflicting, meaning that the added cost of switching patients from generic options to an FDC may not always be justified.

Efficacy of higher-dose 13.3 mg/24 h (15 cm2) rivastigmine patch on the Alzheimer's Disease Assessment Scale-cognitive subscale: domain and individual item analysis.

OBJECTIVE: Rivastigmine displays dose-dependent efficacy on cognition in patients with Alzheimer's disease (AD), as measured by the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog). Subanalysis of the OPTIMA (OPtimising Transdermal Exelon In Mild-to-moderate Alzheimer's disease) study aimed to define ADAS-cog domains by factor analysis of individual items. Efficacy of 13.3 mg/24 h versus 9.5 mg/24 h rivastigmine patch on individual items and newly derived domains was assessed. METHODS: OPTIMA was a 48-week, double-blind (DB) study in patients with mild-to-moderate AD. Patients meeting pre-defined decline criteria during open-label treatment with 9.5 mg/24 h patch were randomized in the DB phase to 13.3 mg/24 h (n = 280) or 9.5 mg/24 h (n = 287) patch. ADAS-cog change from baseline was a co-primary outcome measure. Factor analysis categorized ADAS-cog items into newly derived domains. Change from DB-baseline was calculated for domains and individual items. RESULTS: Numerically, less decline was displayed with 13.3 mg/24 h versus 9.5 mg/24 h patch in the total ADAS-cog score at all time points (significant at Week 24, p = 0.027). Factor analysis identified two domains: memory and language. Significantly, less decline was observed on the memory domain with 13.3 mg/24 h versus 9.5 mg/24 h patch at Weeks 12, 24, and 48 (p < 0.05; observed cases). Three items (following commands, orientation, and word recognition) displayed numerically less decline with 13.3 mg/24 h versus 9.5 mg/24 h patch at all time points. No significant between-group differences were observed on the language domain. CONCLUSION: Results suggest that the greater cognitive efficacy of 13.3 mg/24 h versus 9.5 mg/24 h rivastigmine patch is driven primarily by effects on memory, particularly in the areas of following commands, orientation, and word recognition.

Caregiver health: health of caregivers of Alzheimer's and other dementia patients.

Alzheimer's disease (AD) is the most common type of dementia and is a significant public health problem that will intensify as the population ages. The behavioral and psychological symptoms of dementia (BPSD) present a significant burden to patients, their families, and their caregivers. The majority of care is provided at home by family caregivers. Caring for a person with AD and other dementias is associated with significant risk to the caregiver's health and well-being. Healthcare providers must recognize that family caregivers often present as secondary patients. Given the importance of these caregivers to patients with AD and other dementias, it is vital to understand the risk factors that impact caregiver health and well-being. Non-pharmacological interventions can reduce the negative impact of caregiver burden on caregiver health, reduce premature institutionalization of patients, and improve quality of life for patients, their families, and their caregivers. This article summarizes recent relevant research concerning AD and dementia caregiver health and psychosocial interventions.

Impact of rivastigmine on caregiver burden associated with Alzheimer's disease in both informal care and nursing home settings.

Progressive deterioration in cognitive function and the ability to perform activities of daily living are the hallmarks of Alzheimer's disease (AD). As the disease progresses and behavioural/neuropsychiatric symptoms become more predominant, carers of AD patients themselves encounter a raft of physical, emotional, social and financial problems. Appropriate therapeutic management of AD patients, particularly their behavioural symptoms, may reduce the burden placed on family and professional caregivers. Preservation of cholinergic neurotransmission by cholinesterase inhibitors is the mainstay of pharmacological therapy for AD. Rivastigmine, a dual inhibitor of acetylcholinesterase and butyrylcholinesterase, has pharmacological properties that appear particularly favourable regarding the behavioural symptoms of AD. In addition to its beneficial effects on cognitive and global function, rivastigmine treatment in mild-to-moderate AD is associated with improvements in behavioural symptoms, a decreased requirement for antipsychotic drugs and delays in nursing home placement; reductions in caregiver burden, caregiver time and costs have also been reported. Rivastigmine treatment has also demonstrated improvements in behavioural symptoms and reductions in psychotropic medication usage in nursing home residents with moderate-to-severe AD, and may be associated with a reduction in professional caregiver burden. In summary, the positive effects of rivastigmine on functional and behavioural symptoms of AD help to reduce the time, stress and overall burden associated with caregiving, both in the informal home care and nursing home environments.

Unmet visual needs of Alzheimer's disease patients in long-term care facilities.

INTRODUCTION: The purpose of this study was to determine the prevalence of uncorrected visual disorders in nursing home patients with Alzheimer's disease (AD) and to determine whether appropriate corrective measures were taken by nursing home staff. This study was conducted at 2 community nursing homes in the St Louis area. Whereas previous studies have shown that visual impairment is common among all residents of nursing facilities, our study was focused specifically on residents with AD. This population is less able to effectively express needs and more likely to endure unaddressed visual deficits. For AD patients, it is important to offer appropriate corrective remedies in order to maintain as much functional independence as possible. METHODS: A retrospective cohort study was conducted in 2 private, skilled nursing facilities in St Louis County thought to be representative of community nursing homes in the United States. All subjects were patients with a diagnosis of dementia of probable AD. Demographic information collected included age, sex, and race. Mini-Mental State Examination scores were also obtained. The patients, their families, and nursing staff were interviewed to determine the patients' visual history, corrective measures, and the usage of corrective eyewear before and after admission to the nursing homes. The data were summarized to demonstrate how many patients suffered from uncorrected errors of refraction and what factors contributed to their visual status. RESULTS: Of the total of 85 patients included in the study, 80 (94.1%) required glasses for correction of presbyopia, myopia, or both. However, 25 of the 80 residents had not actively been using glasses since entering the nursing home. Of these 25 residents not wearing proper eyewear, 9 residents were too cognitively impaired to request them, 8 residents had broken or misplaced them, and 8 residents had prescriptions that were no longer sufficient to correct their vision. DISCUSSION: Our study found that nearly one third of the visually impaired nursing home residents with AD (25 of 80 patients) were not using their required eyewear. These 25 patients were the population of most interest because they were most likely to benefit from intervention. Many of these patients were not using glasses because they had been lost, damaged, or were no longer sufficient to correct their vision. CONCLUSIONS: We have presented 3 recommendations intended to prevent uncorrected visual acuity in nursing home residents with dementia: (1) Label eyewear in appropriate patient populations to provide rapid identification in the event of misplacement, (2) recommend that an extra pair of glasses be made available if the current pair would be lost or damaged, and (3) ensure that all residents have annual or biannual eye exams. If adequate steps are taken to prevent unnecessary visual impairment in AD patients, it would limit their dependence on others, reduce the burden on nursing staff, and improve the patients' overall quality of life.

Activities of daily living in patients with dementia: clinical relevance, methods of assessment and effects of treatment.

Disability, characterised by the loss of ability to perform activities of daily living (ADL), is a defining feature of dementia that results in growing caregiver burden and the eventual need for alternative care or nursing home placement. Functional decline in patients with dementia can also result from causes other than dementia, such as comorbid medical and psychiatric illnesses and sensory impairment. ADL consists of instrumental ADL (IADL) [complex higher order skills, such as managing finances] and basic ADL (BADL) [self-maintenance skills, such as bathing]. Assessment of IADL and BADL is recommended to establish a diagnosis of dementia. Functional assessment also helps the healthcare provider to offer appropriate counselling regarding safety concerns and need for custodial care. Functional capacity measures have been used increasingly in pharmacological trials of patients with Alzheimer's disease (AD) and related dementias, although at the present time these measures are generally not primary outcome measures. Functional impairment is not a uniform construct; rather, it is multifaceted and can be measured with various clinical instruments. Many scales have been validated for use in patients with AD for characterising functional impairment and evaluating the efficacy of treatment. Research to date indicates that cholinesterase inhibitors have the potential for modest but meaningful beneficial effects on ADL in patients with mild-to-moderate AD. Memantine also has promising beneficial effects on functional abilities in persons with moderate-to-severe AD. Assessment of ADL as a primary efficacy measure using a validated scale that is non-gender biased and cross-nationally relevant is recommended in new treatment trials of patients with AD and related dementias.

Diagnosis and treatment of Alzheimer's disease.

The defining characteristic of Alzheimer's disease is cognitive impairment, but commonly this impairment is accompanied by mood and behavioral symptoms such as depression, anxiety, irritability, inappropriate behavior, sleep disturbance, psychosis, and agitation. The symptoms of Alzheimer's disease are not normative to the aging process. Diagnosis of Alzheimer's disease in the majority of cases can be made with confidence through office-based clinical assessment and informant interview. Alzheimer's disease is the most common of the dementing disorders and is exponentially increasing in incidence, projected to affect 8.64 million people in the United States by the year 2047. At present, no treatment can prevent or cure Alzheimer's disease, and the fact that Alzheimer's affects a geriatric population makes treatment all the more challenging. Therapies that could delay onset of symptoms even briefly would have a major impact on public health. As the prevalence of Alzheimer's disease increases, researchers are examining the efficacy of treatment options beyond the realm of the established cholinesterase inhibitors.