Mohammed U. Kabeto

National Estimates of the Quantity and Cost of Informal Caregiving for the Elderly with Dementia

AbstractOBJECTIVE: Caring for the elderly with dementia imposes a substantial burden on family members and likely accounts for more than half of the total cost of dementia for those living in the community. However, most past estimates of this cost were derived from small, nonrepresentative samples. We sought to obtain nationally representative estimates of the time and associated cost of informal caregiving for the elderly with mild, moderate, and severe dementia. DESIGN: Multivariable regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people age 70 years or older (N=7,443). SETTING: National population-based sample of the community-dwelling elderly. MAIN OUTCOME MEASURES: Incremental weekly hours of informal caregiving and incremental cost of caregiver time for those with mild dementia, moderate dementia, and severe dementia, as compared to elderly individuals with normal cognition. Dementia severity was defined using the Telephone Interview for Cognitive Status. RESULTS: After adjusting for sociodemographics, comorbidities, and potential caregiving network, those with normal cognition received an average of 4.6 hours per week of informal care. Those with mild dementia received an additional 8.5 hours per week of informal care compared to those with normal cognition (P<.001), while those with moderate and severe dementia received an additional 17.4 and 41.5 hours (P<.001), respectively. The associated additional yearly cost of informal care per case was

Geriatric conditions and disability: the Health and Retirement Study.

3,630 for mild dementia,

The Health Effects of Restricting Prescription Medication Use Because of Cost

7,420 for moderate dementia, and

Trends in the prevalence and mortality of cognitive impairment in the United States: Is there evidence of a compression of cognitive morbidity?

17,700 for severe dementia. This represents a national annual cost of more than

Estimating the Cost of Informal Caregiving for Elderly Patients With Cancer

18 billion. CONCLUSION: The quantity and associated economic cost of informal caregiving for the elderly with dementia are substantial and increase sharply as cognitive impairment worsens. Physicians caring for elderly individuals with dementia should be mindful of the importance of informal care for the well-being of their patients, as well as the potential for significant burden on those (often elderly) individuals providing the care.

Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management?

Context Geriatric conditions, such as incontinence and falling, are prevalent and associated with disability in older adults. Contribution Using national survey data, the authors found that almost half of older U.S. adults had geriatric conditions. Some were as prevalent as common conditions, such as heart disease. The authors confirmed a strong association between having a geriatric condition and dependency in activities of daily living. Caution Conditions and dependence were identified by self-report. Implications Geriatric conditions are often overlooked in older adults, but they are as common as other chronic diseases and are as strongly associated with disability. The Editors Geriatric conditions, such as incontinence and falling, fall outside the traditional disease model of clinical medicine and thus may be overlooked in the care of older adults (1). Yet, these conditions are a necessary focus for geriatricians in their management of patients. A recent American Geriatrics Society statement includes expertise in the diagnosis and care of geriatric conditions among its core attributes and competencies (2). Although certain geriatric conditions have been studied extensively, the aggregate effect of those conditions on health and disability in the older adult population has not been investigated. One obstacle is the lack of consensus on the definition of a geriatric condition or geriatric syndrome (35). Citing an early edition of the Geriatrics Review Syllabus and drawing on other sources (6), Flacker (7) noted that geriatric syndromes are understood to have the following features: They occur in older, especially vulnerable, adults; are multifactorial in cause; are precipitated by a variety of acute insults; are typically episodic in nature; and are often followed by functional decline. This lack of consensus on the definitions leads to variation in what is considered a geriatric condition or geriatric syndrome (4, 5). For instance, there is consensus that cognitive impairment, falls, incontinence, and delirium are geriatric syndromes, but less agreement that malnutrition and neglect and abuse also qualify. In this paper, we use the term geriatric condition and include all conditions for which survey data were available. Use of the term geriatric condition, to indicate a collection of symptoms and signs common in older adults not necessarily related to a specific disease, avoids the ambiguity associated with the term syndrome (2). We examined the association, both individually and in aggregate, between geriatric conditions and dependency in activities of daily living (ADLs) in older Americans. We used nationally representative data that include information on geriatric conditions, chronic diseases, disability, and demographic characteristics. We hypothesized that having 1 or more geriatric conditions is strongly associated with ADL dependency, independent of prevalent diseases. Methods Data We obtained data from the 2000 wave of the Health and Retirement Study (HRS), a biennial longitudinal health interview survey of a cohort of adults age 50 years or older in the United States. Sponsored by the National Institute on Aging and performed by the Institute for Social Research at the University of Michigan, the HRS is designed to study health transitions among older adults (8, 9). Of the 19580 HRS respondents interviewed in 2000, we identified 11093 respondents age 65 years or older, who represented 34.5 million U.S. adults in this age group in that year. The HRS investigators interviewed sampled respondents and their spouses. When the eligible respondent could not be interviewed, often because of medical or cognitive problems, a proxy (n= 1392)frequently the spouse (n= 698)was enlisted to answer questions for that respondent. The HRS was approved by the Behavioral Sciences Committee institutional review board at the University of Michigan. The data used for this analysis are publicly available and contain no unique identifiers, thus ensuring respondent anonymity. Variables and Their Measurement Geriatric Conditions The 2000 wave assessed self-reported information on 7 geriatric conditions and their activity or severity. We used survey data on the following geriatric conditions in their active or severe forms: 1) falls resulting in injury; 2) incontinence requiring use of pads or other absorbent undergarments; 3) low body mass index (BMI) (<18.5 kg/m2, based on self-reported height and weight); 4) dizziness (dizziness or lightheadedness as a persistent or troublesome problem); 5) vision impairment (fair or poor eyesight despite use of corrective lenses); 6) hearing impairment (fair or poor hearing despite use of hearing aids); and 7) cognitive impairment. The HRS assesses for cognitive impairment by 1 of 2 means. For self-respondents, cognitive impairment is determined by using a performance-based measurea modified version of the Telephone Interview for Cognitive Status, which is a validated cognitive screening instrument patterned on the Mini-Mental State Examination (10) and is specifically designed for population-based studies. We defined severe cognitive impairment as a score of 8 or less on the 35-point cognitive scale. This cut-point has previously been used by researchers because the proportion of people that it identifies as having serious cognitive impairment is consistent with other estimates of the prevalence of dementia (1113). Detailed information on the cognitive measures that make up the modified Telephone Interview for Cognitive Status is available on the HRS Web site (hrsonline.isr.umich.edu/docs/userg/dr-006.pdf). Respondents unable to complete the survey interview were assigned proxy respondents by a trained interviewer according to study protocol. Each proxy was asked to assess the respondents memory. Respondents reported to have fair or poor memory were considered to have severe cognitive impairment (13). Disability Of the traditional ADLs (14), we included bathing, dressing, eating, toileting, and transferring in our analysis but excluded continence, because we considered incontinence to be a geriatric condition. Our definition of ADL dependency required respondents to both have difficulty with and receive assistance for the task. Difficulty included the inability to perform the task because of a health or memory problem. Chronic Diseases We considered the following diseases surveyed in the HRS to be chronic: heart disease, chronic lung disease, diabetes, cancer, musculoskeletal conditions, stroke, and psychiatric problems. Respondents reported whether a physician had diagnosed each disease. Questions about the diseases included those indicating their activity or severity (for example, receiving treatment). We limited each chronic disease to its active or severe form. Because our dependent variable was ADL dependency, we tried to avoid activity or severity constraints that were inherently functional in nature (15). For example, musculoskeletal conditions included arthritis requiring medication or other treatment and/or joint replacement in the past 2 years and/or hip fracture in the past 2 years. We limited stroke to persons who required medication for stroke (or its complications) or had remaining problems (such as weakness in arms or legs and difficulty speaking or swallowing). Demographic Factors Demographic variables were age, sex, race (white, African American, other), marital status (married, unmarried), educational attainment, and net financial worth (total household assets minus current debt) (8). Statistical Analysis We used multivariate logistic regression modeling to examine the association between geriatric conditions (numbers of conditions/individual conditions) and the probability of having 1 or more ADL dependencies. Then, we sequentially introduced groups of variables into the model, first demographic variables and then chronic disease variables, because these are known to be associated with ADL dependencies. We used variance inflation factors to investigate and rule out multicollinearity among the independent variables. We obtained estimates of risk ratios from the logistic models. We then used bootstrapping to produce the CIs; we performed the bootstrapping by resampling at the primary sampling unit for the bootstrapping (16). The dependent variables for each model are: any ADL dependency (model 1) and each particular ADL dependency (models 2 to 6). The independent variables for each model are the 7 geriatric conditions. Each model controlled for 6 demographic characteristics and the 7 chronic diseases. Regression diagnostics performed on our initial unweighted models suggested that the logistic regression models were a reasonable fit for our data and that the models evaluating groups of geriatric conditions and groups of diseases showed the best fits. We systematically tested interactions between the independent variables. Those that were considered clinically significant were not statistically significant (for example, vision impairment and hearing impairment), and those that were statistically significant we did not consider to be clinically significant (for example, falls and lung disease). Therefore, we did not include these terms in the final model. To adjust for the complex sample design of the HRS, the differential probability of selection, and nonresponse, all analyses were weighted and adjusted by using the Stata statistical package (release 8.0; Stata, College Station, Texas); thus, we could take advantage of the nationally representative data set to produce national population estimates. Role of the Funding Sources This study was supported by grants from the John A. Hartford Foundation and the National Institute on Aging and by the Ann Arbor Veterans Affairs Geriatric Research, Education and Clinical Center. The funding sources had no role in the design, conduct, or analysis of the study or in the decision to submit the manuscript for publication. Results Ta

Caregiving Behavior Is Associated With Decreased Mortality Risk

Background:High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known. Methods:We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995–1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression. Results:In adjusted analyses, 32.1% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27–2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9% vs. 8.2%; AOR, 1.50; CI, 1.09–2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8% vs. 5.3%; AOR, 1.51; CI, 1.02–2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort. Conclusions:Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012.

Recent medical, demographic, and social trends might have had an important impact on the cognitive health of older adults. To assess the impact of these multiple trends, we compared the prevalence and 2‐year mortality of cognitive impairment (CI) consistent with dementia in the United States in 1993 to 1995 and 2002 to 2004.

Predicting nursing home admission: Estimates from a 7-year follow-up of a nationally representative sample of older Americans

PURPOSE As the United States population ages, the increasing prevalence of cancer is likely to result in higher direct medical and nonmedical costs. Although estimates of the associated direct medical costs exist, very little information is available regarding the prevalence, time, and cost associated with informal caregiving for elderly cancer patients. MATERIALS AND METHODS To estimate these costs, we used data from the first wave (1993) of the Asset and Health Dynamics (AHEAD) Study, a nationally representative longitudinal survey of people aged 70 or older. Using a multivariable, two-part regression model to control for differences in health and functional status, social support, and sociodemographics, we estimated the probability of receiving informal care, the average weekly number of caregiving hours, and the average annual caregiving cost per case (assuming an average hourly wage of

A national study of the quantity and cost of informal caregiving for the elderly with stroke

8.17) for subjects who reported no history of cancer (NC), having a diagnosis of cancer but not receiving treatment for their cancer in the last year (CNT), and having a diagnosis of cancer and receiving treatment in the last year (CT). RESULTS Of the 7,443 subjects surveyed, 6,422 (86%) reported NC, 718 (10%) reported CNT, and 303 (4%) reported CT. Whereas the adjusted probability of informal caregiving for those respondents reporting NC and CNT was 26%, it was 34% for those reporting CT (P <.05). Those subjects reporting CT received an average of 10.0 hours of informal caregiving per week, as compared with 6.9 and 6.8 hours for those who reported NC and CNT, respectively (P <.05). Accordingly, cancer treatment was associated with an incremental increase of 3.1 hours per week, which translates into an additional average yearly cost of