Margaret Sewell

The Economics of Caring for Individuals with Alzheimer’s Disease

The devastation of Alzheimer’s disease (AD) is well known. It robs victims of cognitive ability and eventually steals their ability to function independently. To manage this loss of independence, individuals with AD receive care from a wide variety of sources. Most patients with AD prefer to live at home for as long as possible before disease progression makes home living difficult or impossible and the patient is institutionalized. Although preference of home living and the need to curb high cost of institutionalization concur with each other, the care provided at home comes at tremendous cost to the family and friends of AD patients both financially and also in terms of human cost. Estimating the economic value of the system of care at home for the AD patient is difficult. In this chapter, we will explore economic issues associated with caring for AD patients. Models of cost estimation will be reviewed. Sources, distribution, who pays for the costs of care, and factors that affect costs of care will be discussed. The perspectives of the payer and of the caregiver will be addressed. The human costs of care and cultural differences will be explored. Early diagnosis and treatment and their effect on caregiving cost will be discussed.

Delineating the Trajectory of Cognitive Recovery From General Anesthesia in Older Adults: Design and Rationale of the Torie (trajectory of Recovery in the Elderly) Project

BACKGROUND: Mechanistic aspects of cognitive recovery after anesthesia and surgery are not yet well characterized, but may be vital to distinguishing the contributions of anesthesia and surgery in cognitive complications common in the elderly such as delirium and postoperative cognitive dysfunction. This article describes the aims and methodological approach to the ongoing study, Trajectory of Recovery in the Elderly (TORIE), which focuses on the trajectory of cognitive recovery from general anesthesia. METHODS: The study design employs cognitive testing coupled with neuroimaging techniques such as functional magnetic resonance imaging, diffusion tensor imaging, and arterial spin labeling to characterize cognitive recovery from anesthesia and its biological correlates. Applying these techniques to a cohort of age-specified healthy volunteers 40–80 years of age, who are exposed to general anesthesia alone, in the absence of surgery, will assess cognitive and functional neural network recovery after anesthesia. Imaging data are acquired before, during, and immediately after anesthesia, as well as 1 and 7 days after. Detailed cognitive data are captured at the same time points as well as 30 days after anesthesia, and brief cognitive assessments are repeated at 6 and 12 months after anesthesia. RESULTS: The study is underway. Our primary hypothesis is that older adults may require significantly longer to achieve cognitive recovery, measured by Postoperative Quality of Recovery Scale cognitive domain, than younger adults in the immediate postanesthesia period, but all will fully recover to baseline levels within 30 days of anesthesia exposure. Imaging data will address systems neuroscience correlates of cognitive recovery from general anesthesia. CONCLUSIONS: The data acquired in this project will have both clinical and theoretical relevance regardless of the outcome by delineating the mechanism behind short-term recovery across the adult age lifespan, which will have major implications for our understanding of the effects of anesthetic drugs.

Attitudes and Perceptions of Research in Aging and Dementia in an Urban Minority Population

In dementia trials, minority participation is low. We assessed attitudes toward research in a community based urban poor minority sample of elderly adults attending senior center talks using the 7-item Research Attitudes Questionnaire (RAQ). Presentations on cognitive aging were given at senior centers, and 123 attendees completed the RAQ-7. On trust and safety questions, a significant minority (42-48%) responded neutrally or negatively. Encouragingly, on questions concerning the importance of research, 72-81% answered positively. More work can be done to capitalize on these findings to engage and foster trust, and this can be a focus of outreach.

Detection of mild cognitive impairment and early stage dementia with an audio-recorded cognitive scale.

BACKGROUND Physicians often miss diagnosis of mild cognitive impairment (MCI) or early dementia and screening measures can be insensitive to very mild impairments. Other cognitive assessments may take too much time or be frustrating to seniors. This study examined the ability of an audio-recorded scale, developed in Australia, to detect MCI or mild Alzheimers disease (AD) and compared cognitive domain-specific performance on the audio-recorded scale to in-person battery and common cognitive screens. METHOD Seventy-six patients from the Mount Sinai Alzheimers Disease Research Center were recruited. Patients were aged 75 years or older, with clinical diagnosis of AD or MCI (n = 51) or normal control (n = 25). Participants underwent in-person neuropsychological testing followed by testing with the audio-recorded cognitive screen (ARCS). RESULTS ARCS provided better discrimination between normal and impaired elderly individuals than either the Mini-Mental State Examination or the clock drawing test. The in-person battery and ARCS analogous variables were significantly correlated, most in the 0.4 to 0.7 range, including verbal memory, executive function/attention, naming, and verbal fluency. The area under the curve generated from the receiver operating characteristic curves indicated high and equivalent discrimination for ARCS and the in-person battery (0.972 vs. 0.988; p = 0.23). CONCLUSION The ARCS demonstrated better discrimination between normal controls and those with mild deficits than typical screening measures. Performance on cognitive domains within the ARCS was well correlated with the in-person battery. Completion of the ARCS was accomplished despite mild difficulty hearing the instructions even in very elderly participants, indicating that it may be a useful measure in primary care settings.

RESEARCH SATISFACTION IN ALZHEIMER’S TRIALS AND STUDIES AMONG PARTICIPANTS AND STUDY PARTNERS

BMI -0.324 0.057 0.630 0.073 24.80 3.88 28.97 3.73 12.57 <0.001 CIMT -0.194 0.051 0.216 0.082 0.70 0.07 0.74 0.10 5.250 <0.001 LDL-C -0.240 0.064 0.323 0.069 121.89 28.91 138.35 28.23 6.620 <0.001 HDL-C 0.498 0.055 -0.779 0.065 74.13 15.20 51.22 9.80 -21.751 <0.001 Triglycerides -0.510 0.051 0.755 0.086 66.73 25.74 129.26 60.24 14.402 <0.001 FSG -0.188 0.049 0.361 0.083 87.31 8.46 92.73 9.78 6.718 <0.001 FPS -0.564 0.059 0.857 0.063 2.16 2.25 6.89 2.14 25.926 <0.001 Latent Prevalence (Marginal Probability) 62% 38%