Lisa Mucha

Dependence as a Unifying Construct in Defining Alzheimer's Disease Severity

This article reviews measures of Alzheimers disease (AD) progression in relation to patient dependence and offers a unifying conceptual framework for dependence in AD. Clinicians typically characterize AD by symptomatic impairments in three domains: cognition, function, and behavior. From a patients perspective, changes in these domains, individually and in concert, ultimately lead to increased dependence and loss of autonomy. Examples of dependence in AD range from a need for reminders (early AD) to requiring safety supervision and assistance with basic functions (late AD). Published literature has focused on the clinical domains as somewhat separate constructs and has given limited attention to the concept of patient dependence as a descriptor of AD progression. This article presents the concept of dependence on others for care needs as a potential method for translating the effect of changes in cognition, function, and behavior into a more holistic, transparent description of AD progression.

A review of the methods used to estimate the cost of Alzheimer’s disease in the United States

Background/Rationale: To determine the suitability of published estimates of the US cost of Alzheimer’s disease (AD) for use in cost-effectiveness models for new AD treatments. Methods: A systematic literature review of published information on direct medical, direct nonmedical, indirect, and informal care costs for different levels of disease severity. Results: Nineteen studies were included in the review. In studies presenting mean costs by disease severity, the change in different types of costs with increasing disease severity varied, depending on the data sources and characteristics of patients with AD. In studies presenting the results of regression analyses, costs were shown to be independently associated with cognition, functional status, behavioral symptoms, and dependence. Conclusions: Published US studies (1) did not include all the types of costs and AD populations, and (2) generally did not include all the measures of disease severity that are needed for cost-effectiveness models.

A Qualitative Assessment of the Concept of Dependence in Alzheimer’s Disease

Background: The Dependence Scale (DS) was designed to assess levels of patient need for care due to deficits typical of Alzheimer’s disease (AD). This study examined content validity of the DS based on input from patients, caregivers, and clinicians. Methods: Qualitative interviews with experts, patients, and caregivers were used to collect information on the concept of dependence and to assess content validity. Results: Nine clinicians rated item relevance ‘‘high’’ with consensus on the primacy of functional abilities and dependence in the measurement of AD progression. Twenty-two US, 11 UK, and 14 informal caregivers from Spain participated in focus groups; 18 patients participated in 3 separate focus groups. Discussion supported DS hierarchy of dependence, capture of mild-to-severe dependence, suitability of response options, and short recall time frame. Conclusions: Clinicians, caregivers, and patients support content validity of the DS in mild-to-moderate AD. The DS may be valuable to capture dependence within future clinical dementia trials.

Staging Dementia From Symptom Profiles on a Care Partner Website

Background The World Wide Web allows access to patient/care partner perspectives on the lived experience of dementia. We were interested in how symptoms that care partners target for tracking relate to dementia stage, and whether dementia could be staged using only these online profiles of targeted symptoms. Objectives To use clinical data where the dementia stage is known to develop a model that classifies an individual’s stage of dementia based on their symptom profile and to apply this model to classify dementia stages for subjects from a Web-based dataset. Methods An Artificial Neural Network (ANN) was used to identify the relationships between the dementia stages and individualized profiles of people with dementia obtained from the 60-item SymptomGuide (SG). The clinic-based training dataset (n=320), with known dementia stages, was used to create an ANN model for classifying stages in Web-based users (n=1930). Results The ANN model was trained in 66% of the 320 Memory Clinic patients, with the remaining 34% used to test its accuracy in classification. Training and testing staging distributions were not significantly different. In the 1930 Web-based profiles, 309 people (16%) were classified as having mild cognitive impairment, 36% as mild dementia, 29% as moderate, and 19% as severe. In both the clinical and Web-based symptom profiles, most symptoms became more common as the stage of dementia worsened (eg, mean 5.6 SD 5.9 symptoms in the MCI group versus 11.9 SD 11.3 in the severe). Overall, Web profiles recorded more symptoms (mean 7.1 SD 8.0) than did clinic ones (mean 5.5 SD 1.8). Even so, symptom profiles were relatively similar between the Web-based and clinical datasets. Conclusion Symptoms targeted for online tracking by care partners of people with dementia can be used to stage dementia. Even so, caution is needed to assure the validity of data collected online as the current staging algorithm should be seen as an initial step.

Road to the Nursing Home Costs and Disease Progression Among Medicare Beneficiaries With ADRD

Objectives: To estimate long-term care costs and disease progression among Medicare beneficiaries aged 65+ with ADRD. Methods: Retrospective analysis of Medicare Part A claims and nursing home (NH) Minimum Data Set (MDS) records among beneficiaries 1999-2007. Expenditures were grouped into 3 periods; PRE, events occurring between date of ADRD diagnosis, before first NH admission; PERI, from first NH admission to at least 100 days; and, PERM, after 120 days. Utilization and reimbursements were computed for each period. Results: Demographics of the3,681,702 ADRD beneficiaries showed average age of 83 (+/−7), female (67.7%) and white (87.4%). Medicare reimbursements per person increased by 58% from the PRE (

Relationship between patient dependence on others and caregiver burden in Alzheimer's Disease (AD)

47,912) to PERM period (

Increased risk of serious comorbidities in a cohort of AD patients compared to a similar non-AD cohort

75,654). Age, ethnicity, gender (male), and comorbidities were significantly related to total reimbursements in each phase. Conclusions: Applying a taxonomy of NH phases, Medicare expenditures per person year are higher among patients in their terminal phase and higher still with comorbidities.

The incremental effect of Alzheimer's disease on direct health care costs and utilization in a Medicaid population

ADRDA criteria. Cognitive functions were assessed using K-MMSE , KCDR and Seoul Neuropsychological Screening Battery. The frequency and severity of NPS were evaluated with of K-NPI. MRI or PET-CT of brain was applied to all patients. In general AD was classified as mild, moderate, severe and the corresponding K-MMSE scores are 20-24, 10-19, 0-9, the CDR scores are 0.5-1, 2-3, 4-5 But these are too wide range of scores in each group that might prevent which symptoms are frequent in exact phase or severity of disease, so we try to more subdivide into 6 groups, I(0-5), II(69), III (10-14), IV(15-19), V(20-24), VI (25<) in K-MMSE and I(0.5) , II(1), III (2), IV (3), V (4), VI (5) in CDR. We also evaluate correlation between ADL , Instrumental ADL and NPS. Results: Elation, euphoria were dominant in group IV in K-MMSE and group II in CDR. Delusion, apathy, indifference, aberrant motor behavior, sleep, night time behavior, appetite, eating change were high in group II in K-MMSE & III in CDR. Hallucination, agitation, aggression, depression, anxiety, disinhibition, irritability was frequent in group I in K-MMES & IV in CDR. Delusion, hallucination, disinhibition were high correlated with K-MMSE (p<0.05). Halluciantion, depression, dysphoria, disinhibition, irritability and aberrant behaviour were well related with CDR (p<0.05). Not only Barthel index was highly correlation with anxiety (r1⁄40.96), aberrant behavior (r1⁄40.86) but also instrumental ADL was related to CDR (r1⁄40.72). Conclusions: Although more than half of AD patients who visited to memory clinic are in mild stage of dementia, most of NPS of AD were common in group I & II in K-MMSE and III, IV in CDR except elation & euphoria. Subdivision of AD patient’s stage shows more detail status of NPI than previous reports.

Use of informant-reported web-based data collection to assess dementia symptoms: Validation in relation to the dependence scale

Background: Elderly persons often have multiple conditions that increase the complexity of care. The literature on the relationship between Alzheimer’s Disease (AD) and prevalence of other serious conditions is sparse. The study objective was to examine the association between serious health conditions and AD among an insured population residing in the United States. Methods: Medical and pharmacy administrative data for over 33 million Americans from July 1, 1999 to December 31, 2007 were analyzed. Persons with a diagnosis of AD were identified and followed for 6 months prior to their initial AD claim (index date) through at least 12 months after. Inclusion criteria also included age 40þ and survival of >12 months after the index date. A comparison cohort without evidence of AD or dementia was matched based on age, sex, health plan type, index quarter/year and length of follow-up. Analyses examined the incidence of 17 pre-specified comorbidities/events, including mental health conditions, injuries, decubitus ulcers, diabetes, hyperlipidemia, hypertension, Parkinson’s, epilepsy, anemia, and malnutrition based on diagnosis codes. Incident rate ratios (IRR) were estimated for each condition between those with and without AD. Results: 10,576 subjects with AD and 10,576 matched non-AD subjects were identified. Overall, 59% were female and the average age was 76 years. Mean (SD) follow-up time was 823 (436) days in both cohorts. The most frequent conditions at baseline in both groups were hypertension (AD:46%, nonAD:45%), hyperlipidemia (AD:33%, non-AD:36%), and osteoarthritis (AD:17%, non-AD:16%). The highest IRRs (AD/matched) were psychosis (IRR:13.6, 95%CI:11.5-16.2); Parkinson’s Disease (IRR:9.6, 95%CI:7.712.1), decubitus ulcer (IRR:5.2, 95%CI:4.4-6.0), epilepsy (IRR:4.4, 95%CI:4.1-4.7), depression (IRR:3.9, 95%CI:3.6-4.2), hip fractures (IRR:3.6, 95%CI:2.9-3.9), and pneumonia (IRR:2.3, 95%CI:2.2-2.5) where an IRR >1.0 indicates increased rates in the AD cohort. The IRRs were significant and greater than 1.0 for all comorbidities except for diabetes and hyperlipidemia. Conclusions: AD patients appear to have a higher prevalence of other serious conditions compared to patients without AD. Most notable in this study was the higher incidence of decubitus ulcers, seizures, hip factures, depression, and pneumonia, all having IRRs greater than 2.00 indicating substantial risk among persons with AD relative to those without AD.

Ethnic/Cultural differences in the incremental cost of health care services associated with Alzheimer's disease

inNewYork.Out of 2,453 subjects of the original sample, 198were diagnosed as demented (prevalent). The remaining 2,254 subjects formed the incidence study sample and were re-examined at least once from 2001 to 2009, the average number of years of follow-up for all was 3.6 y6 3. Incident cases were diagnosed using the same procedures and criteria from baseline. Results: A total of 73 incident cases of dementia were identified; 41 of them (56.2%) had AD; 26 (35.6%) had VaD. The annual incidence rate for dementia (per 1000 person-years [py] of follow-up) of all causes was 9.10 (8,026 py of follow up); for AD 5.18 (7,916 py of follow up); and for VaD is 3.35 (7,757 py of follow up). For all dementia, AD and VaD, incidence rates increased steeply with age, and there were no consistent differences between men and women. Conclusions: Incidence of dementia in the population of the Maracaibo Aging Study is much higher than any other incidence rates of dementia in developing countries and many developed countries. Incidence was higher for AD than for any other dementia. The high incidence of VaD offers important opportunity for prevention. Sustained and stronger efforts are needed to prevent and provide care for victims of dementia.