Incremental direct and indirect costs of untreated vasomotor symptoms.

OBJECTIVE: Most women with moderate to severe vasomotor symptoms (VMS) are untreated. This retrospective matched-cohort study aims to evaluate the healthcare resource utilization, work loss, and cost burden associated with untreated VMS. METHODS: Health insurance claims (1999-2011) were used to match (1:1) women with untreated VMS with control women using propensity score. Healthcare resource utilization, work productivity loss (disability + medically related absenteeism), and associated costs were compared between cohorts. RESULTS: During the 12-month follow-up, women with untreated VMS (n = 252,273; mean age, 56 y) had significantly higher healthcare resource utilization than women in the control cohort: 82% higher for all-cause outpatient visits (95% CI, 81-83; P < 0.001) and 121% higher (95% CI, 118-124; P < 0.001) for VMS-related outpatient visits. Mean direct costs per patient per year were significantly higher for VMS women (direct cost difference, US$1,346; 95% CI, 1,249-1,449; P < 0.001). VMS women had 57% (95% CI, 51-63; P < 0.001) more indirect work productivity loss days than controls, corresponding to an incremental indirect cost per patient per year associated with untreated VMS of US$770 (95% CI, 726-816; P < 0.001). CONCLUSIONS: This study shows that untreated VMS are associated with significantly higher frequency of outpatient visits and incremental direct and indirect costs.

Navigating patients and caregivers through the course of Alzheimer's disease.

Alzheimer's disease (AD) prevalence rates in the United States are expected to triple over the next 50 years, a consequence of the overall aging of the U.S. population. Because of the profound and far-reaching impact of AD, this projected increase in prevalence is expected to pose a tremendous challenge. Alzheimer's disease results in the cognitive and functional deterioration of the affected patient, and behavioral disturbances frequently accompany the disease. Furthermore, because of its progressive and debilitating nature, AD takes a dramatic emotional, physical, and financial toll on the patient's primary caregiver. Nonetheless, despite the burden experienced by both patients and caregivers, strategies for minimizing the negative consequences of AD are well characterized. Central to the successful management of AD is the prompt and accurate diagnosis of the disease, with current guidelines calling for a 2-tiered approach in which patients first undergo screening using a brief cognitive assessment tool, followed by a comprehensive battery of physical, psychological, and neurologic tests if signs of possible cognitive impairment are evident upon screening. Once a conclusive diagnosis of AD has been made, the development of a disease management approach targeting the needs of the patient and his or her caregiver becomes a primary concern. Pharmacologic interventions may play an important role in such approaches, as agents such as cholinesterase inhibitors and the N-methyl-D-aspartate receptor antagonist memantine have been associated with favorable outcomes for patients and caregivers alike. However, in addition to the therapeutic benefits of these agents, associated side effects and potential drug-drug interactions must also factor into decisions regarding the pharmacologic treatment of AD.

Hospice use for the patient with advanced Alzheimer's disease: the role of the geriatric psychiatrist.

Advanced Alzheimer's disease (AD) can place an immense burden on caregivers as they struggle to provide end-of-life (EOL) care for the patient. Palliative care, as delivered by hospice, provides a viable solution. Hospice maintains the patient's quality of life (QOL) and helps the family during the grieving process. However, many providers are not familiar with hospice and its care for advanced AD patients. Geriatric psychiatrists can be central in implementing hospice, and they can remain an important part of the care once it is in place. A principal clinical challenge is establishing the six-month prognosis for such patients, which is a prerequisite for initiating hospice admission.

Long-term effects of rivastigmine treatment on neuropsychiatric and behavioral disturbances in nursing home residents with moderate to severe Alzheimer's disease: results of a 52-week open-label study.

OBJECTIVES: To evaluate the safety and efficacy of long-term treatment with rivastigmine (3-12 mg/day) and its effects on neuropsychiatric and behavioral disturbances in nursing home patients with moderate to severe probable Alzheimer's disease (AD). METHODS: A prospective, multicenter 26-week open-label extension to a 26-week open-label study (52 week results) of rivastigmine treatment in patients with Mini-Mental State Examination (MMSE) scores of 6-15 inclusive, residing in nursing homes at 13 centers in the US. Effects of treatment with rivastigmine for up to 52 weeks on neuropsychiatric and behavioral symptoms were examined using the Neuropsychiatric Inventory-Nursing Home (NPI-NH) scale. Cognitive function was assessed by the MMSE, and the Naming Objects and Fingers Test (NOFT) subset of the Alzheimer's Disease Assessment Scale -- Cognitive subscale (ADAS-Cog). Global functioning was assessed using the simplified Clinician's Interview-Based Impression of Change Plus Caregiver Input (CIBIC-Plus). RESULTS: Rivastigmine (3-12 mg/day) significantly improved neuropsychiatric and behavioral symptoms compared to baseline (in patients with specific behavioral disturbances at baseline) in observed cases (OC) and last observation carried forward (LOCF) analyses. Over 52 weeks, treatment with rivastigmine significantly improved 10 of 12 individual NPI-NH domains from baseline in LOCF patients with symptoms present at baseline. Cognitive function was stable, indicated by the lack of decline in MMSE and the NOFT. Global function was stabilized or improved in greater than half of the patients as indicated by the simplified CIBIC-Plus scores. CONCLUSION: Rivastigmine showed potential benefit in the long-term treatment of behavioral symptoms as well as cognitive and global functioning in nursing home residents with moderate to severe AD with concurrent behavioral symptoms present at baseline. Although these results suggest that treatment with rivastigmine may have beneficial behavioral effects and cognitive benefits on patients with moderate to severe AD, they are subject to the limitations of an open-label study.

Hospice use for the patient with advanced Alzheimer's disease: the role of the geriatric psychiatrist.

Advanced Alzheimer's disease (AD) can place an immense burden on caregivers as they struggle to provide end-of-life (EOL) care for the patient. Palliative care, as delivered by hospice, provides a viable solution. Hospice maintains the patient's quality of life (QOL) and helps the family during the grieving process. However, many providers are not familiar with hospice and its care for advanced AD patients. Geriatric psychiatrists can be central in implementing hospice, and they can remain an important part of the care once it is in place. A principal clinical challenge is establishing the six-month prognosis for such patients, which is a prerequisite for initiating hospice admission.

Health service utilization by Alzheimer's disease patients: a 2-year follow-up of primary versus subspecialty care.

All dementia patients and their caregivers who had received a university-based comprehensive evaluation and a diagnosis of Alzheimer's disease during 1997 (N = 80) were identified. Of the original cohort, 48.8% (n = 39) were able to be contacted approximately 2 years after their initial assessment, and the caregivers were the informants for this follow-up. Two subgroups were defined: 22 patients were being seen only by their primary care physicians (MED), while 17 patients were also being treated by a geriatric psychiatry faculty member (GERO). There were statistically significant differences between the 2 groups (MED versus GERO, respectively) at follow-up in terms of (1) institutionalization (30.0% versus 4.6%, P < .05), (2) CDR (2.3 versus 1.5, P < .005), and (3) prescription of donepezil at follow-up (45.5% versus 76.5%, P = .05). These differences are being assessed in a larger scale prospective study.