And Related Dementias Diagnosis Research Articles

Using Natural Language Processing to Identify Home Health Care Patients at Risk for Diagnosis of Alzheimer's Disease and Related Dementias.

This study aimed to: (1) validate a natural language processing (NLP) system developed for the home health care setting to identify signs and symptoms of Alzheimer's disease and related dementias (ADRD) documented in clinicians' free-text notes; (2) determine whether signs and symptoms detected via NLP help to identify patients at risk of a new ADRD diagnosis within four years after admission. This study applied NLP to a longitudinal dataset including medical record and Medicare claims data for 56,652 home health care patients and Cox proportional hazard models to the subset of 24,874 patients admitted without an ADRD diagnosis. Selected ADRD signs and symptoms were associated with increased risk of a new ADRD diagnosis during follow-up, including: motor issues; hoarding/cluttering; uncooperative behavior; delusions or hallucinations; mention of ADRD disease names; and caregiver stress. NLP can help to identify patients in need of ADRD-related evaluation and support services.

Surgical outcomes and healthcare expenditures among patients with dementia undergoing major surgery.

We sought to define surgical outcomes among elderly patients with Alzheimer's disease and related dementias (ADRD) following major thoracic and gastrointestinal surgery. A retrospective cohort study was used to identify patients who underwent coronary artery bypass grafting (CABG), abdominal aortic aneurysm (AAA) repair, pneumonectomy, pancreatectomy, and colectomy. Individuals were identified from the Medicare Standard Analytic Files and multivariable regression was utilized to assess the association of ADRD with textbook outcome (TO), expenditures, and discharge disposition. Among 1,175,010 Medicare beneficiaries, 19,406 (1.7%) patients had a preoperative diagnosis of ADRD (CABG: n=1,643, 8.5%; AAA repair: n=5,926, 30.5%; pneumonectomy: n=590, 3.0%; pancreatectomy: n=181, 0.9%; and colectomy: n=11,066, 57.0%). After propensity score matching, patients with ADRD were less likely to achieve a TO (ADRD: 31.2% vs. no ADRD: 40.1%) or be discharged to home (ADRD: 26.7% vs. no ADRD: 46.2%) versus patients who did not have ADRD (both p<0.001). Median index surgery expenditures were higher among patients with ADRD (ADRD: $28,815 [IQR $14,333-$39,273] vs. no ADRD: $27,101 [IQR $13,433-$38,578]; p<0.001) (p<0.001). On multivariable analysis, patients with ADRD had higher odds of postoperative complications (OR 1.32, 95% CI 1.25-1.40), extended length-of-stay (OR 1.26, 95% CI 1.21-1.32), 90-day readmission (OR 1.37, 95% CI 1.31-1.43), and 90-day mortality (OR 1.76, 95% CI 1.66-1.86) (all p<0.001). Preoperative diagnosis of ADRD was an independent risk factor for poor postoperative outcomes, discharge to non-home settings, as well as higher healthcare expenditures. These data should serve to inform discussions and decision-making about surgery among the growing number of older patients with cognitive deficits.

Impact of dementia and socioeconomic disadvantage on days at home after traumatic brain injury among older Medicare beneficiaries: A cohort study.

Time spent at home may aid in understanding recovery following traumatic brain injury (TBI) among older adults, including those with Alzheimer's disease and related dementias (ADRD). We examined the impact of ADRD on recovery following TBI and determined whether socioeconomic disadvantages moderated the impact of ADRD. We analyzed Medicare beneficiaries aged ≥65 years diagnosed with TBI in 2010-2018. Home time was calculated by subtracting days spent in a care environment or deceased from total follow-up, and dual eligibility for Medicaid was a proxy for socioeconomic disadvantage. A total of 2463 of 20,350 participants (12.1%) had both a diagnosis of ADRD and were Medicaid dual-eligible. Beneficiaries with ADRD and Medicaid spent markedly fewer days at home following TBI compared to beneficiaries without either condition (rate ratio 0.66; 95% confidence interval [CI] 0.64, 0.69). TBI resulted in a significant loss of home time over the year following injury among older adults with ADRD, particularly for those who were economically vulnerable. Remaining at home after serious injuries such as fall-related traumatic brain injury (TBI) is an important goal for older adults. No prior research has evaluated how ADRD impacts time spent at home after TBI. Older TBI survivors with ADRD may be especially vulnerable to loss of home time if socioeconomically disadvantaged. We assessed the impact of ADRD and poverty on a novel DAH measure after TBI. ADRD-related disparities in DAH were significantly magnified among those living with socioeconomic disadvantage, suggesting a need for more tailored care approaches.

Care sequences leading to the diagnosis of Alzheimer's disease and related dementias: An analysis of electronic health records.

We examined the sequences of clinical care leading to diagnoses of Alzheimer's disease and related dementias (ADRD) using electronic health records from a large academic medical center. We included patients aged 65+ with their first ADRD diagnoses from January 1, 2014 to December 31, 2019. Using state sequence analysis, care sequences were defined by the ordering of healthcare utilizations occurred in the 2 years before ADRD diagnosis. Of 3621 patients (median age 80), nearly half followed a care sequence of having one primary care visit close to their ADRD diagnosis. Additional care sequences included periodic (n=322, 8.9%) and multiple (n=416, 11.5%) outpatient visits to primary care and having one (n=395, 10.9%), multiple (n=469, 13.0%), or highly frequent (n=357, 10.7%) outpatient visits to other specialties. Patients' sociodemographic traits contributed to the variability in care sequences. Several distinct patterns of care leading to ADRD diagnoses were identified. Integrated care models are needed to promote early identification of ADRD. Dementia patients followed distinct care pathways prior to their dementia diagnoses. Key sociodemographic traits contributed to the variation in the sequences of care. Racial differences in the sequencing of care were also found, but only in women.

Participant completion of longitudinal assessments in an online cognitive aging registry: The role of medical conditions.

This study aimed to understand whether older adults' longitudinal completion of assessments in an online Alzheimer's disease and related dementias (ADRD)-related registry is influenced by self-reported medical conditions. Brain Health Registry (BHR) is an online cognitive aging and ADRD-related research registry that includes longitudinal health and cognitive assessments. Using logistic regressions, we examined associations between longitudinal registry completion outcomes and self-reported (1) number of medical conditions and (2) eight defined medical condition groups (cardiovascular, metabolic, immune system, ADRD, current psychiatric, substance use/abuse, acquired, other specified conditions) in adults aged 55+ (N = 23,888). Longitudinal registry completion outcomes were assessed by the completion of the BHR initial questionnaire (first questionnaire participants see at each visit) at least twice and completion of a cognitive assessment (Cogstate Brief Battery) at least twice. Models included ethnocultural identity, education, age, and subjective memory concern as covariates. We found that the likelihood of longitudinally completing the initial questionnaire was negatively associated with reporting a diagnosis of ADRD and current psychiatric conditions but was positively associated with reporting substance use/abuse and acquired medical conditions. The likelihood of longitudinally completing the cognitive assessment task was negatively associated with number of reported medical conditions, as well as with reporting cardiovascular conditions, ADRD, and current psychiatric conditions. Previously identified associations between ethnocultural identity and longitudinal assessment completion in BHR remained after accounting for the presence of medical conditions. This post hoc analysis provides novel, initial evidence that older adults' completion of longitudinal assessments in an online registry is associated with the number and types of participant-reported medical conditions. Our findings can inform future efforts to make online studies with longitudinal health and cognitive assessments more usable for older adults with medical conditions. The results need to be interpreted with caution due to selection biases, and the under-inclusion of minoritized communities.

IDENTIFYING NEW ADRD DIAGNOSES IN HOME HEALTH CARE PATIENTS USING NATURAL LANGUAGE PROCESSING OF NURSES’ NOTES

Abstract Patients at risk of developing Alzheimer’s Disease and Related Dementias (ADRD) admitted to home health care (HHC) may show signs of the disease before receiving a formal diagnosis. HHC nurses are uniquely positioned to observe signs of patients’ cognitive symptoms and may record them in free-text notes in the electronic health record (EHR). We applied natural language processing (NLP) to approximately 1.8 million nurses’ notes to identify signs and symptoms of ADRD in a retrospective cohort of 56,652 patients receiving care from a large HHC agency. In a subset of 38,032 patients starting HHC without an ADRD diagnosis, we used survival analysis competing risks models to examine associations between NLP-derived indicators of ADRD constructs during the HHC episode and new ADRD diagnoses during a four-year follow-up period, adjusting for patient demographics, clinical characteristics, and functional status derived from structured standard assessment tools. By the end of follow-up, 23% of the patients were newly diagnosed with ADRD, while 35% died without a diagnosis. We observed higher 4-year cumulative incidence rates of ADRD when more ADRD-related symptoms were present in the nurses’ notes (e.g., confusion only, 0.35, 95% CI: 0.32; 0.38, memory loss only, 0.38, 95% CI: 0.36, 0.39; both, 0.52, 95% CI: 0.48, 0.56; none, 0.10, 95% CI 0.097, 0.103). These findings indicate that data from free-text notes taken during HHC serve as significant predictors for potential ADRD diagnoses. Such information can facilitate prompt specialist referrals, allowing for early diagnosis and potentially more effective treatments during the disease’s initial stages.

FEASIBILITY AND ACCEPTABILITY OF USING PLASMA BIOMARKERS FOR DIAGNOSING ALZHEIMER’S DISEASE IN PRIMARY CARE

Abstract Blood-based biomarkers (Aβ, P-tau, neurofilament light) are clinically available to aid in the diagnosis of Alzheimer’s disease and related dementias (ADRD). However, no research has examined the use of blood biomarkers to aid in the diagnosis of ADRD in primary care (PC). Our study will test feasibility and acceptability of implementing blood-based biomarkers for ADRD in PC. Participants include: all PC patients ≥65 years presenting to one of six PC clinics between 6/1/22 and 5/31/23 who score cognitively impaired on the Linus Health Digital Clock and Recall (DCR™), and PC providers (PCPs) of these patients. Patients will view a decision guide about biomarkers and complete the Concerns about Alzheimer’s Disease Dementia Scale, and the Future Time Perspective Scale and the Impact of Events Scale. These measures and the PHQ-9 and GAD-7 will be repeated within 2 weeks of results disclosure. PCPs will receive training on biomarker disclosure techniques and best practices. To date 9 PCPs have consented to provide the biomarker results disclosure and 11 have declined. Following completion of PCP consent (n=100), a total of 200 patients who failed the DCR are eligible to be approached for consent. By November 2023, we anticipate that 150 patients will have completed biomarker testing, and we will have examined the biomarker results in the context of patient neuropsychological and clinical data, comorbidities, and sociodemographic information. This study will provide information regarding feasibility and utility of ADRD biomarkers in PC and a preliminary analysis of biomarker results compared with the patients’ clinical profiles.

EFFECTS OF DISCLOSING DIAGNOSES AND BIOMARKER RESULTS FOR ALZHEIMER’S DISEASE AND RELATED DISORDERS

Abstract Early diagnosis of mild cognitive impairment (MCI) and Alzheimer’s disease and related dementias (ADRD) has been recognized as a key strategy to improve health-related outcomes. However, given that these conditions are highly stigmatized, receiving a diagnostic label or knowing about biomarkers related to MCI or ADRD may have a profound impact on the person’s life. As the impacts of disclosure of diagnostic information related to MCI and ADRD on the well-being of people living with these conditions are not well understood, this symposium attempts to address this knowledge gap. The first presenter will describe a study that examined racial/ethnic variations in the effects of diagnostic labeling of ADRD on social aspects of the person’s life. The second presenter will discuss findings from a systematic review of the effects of ADRD and cognitive impairment on social engagement. The third presenter will present the findings of the study on the effect of amyloid PET results disclosure on health-related behaviors of people with MCI. The fourth presenter will describe the results of an online vignette study on the outcomes of a preclinical Alzheimer disease diagnosis. The fifth presenter will discuss the use of blood biomarkers to aid in the diagnosis of ADRD in primary care (PC). At the end of the presentation, the discussant will highlight implications for future research and policy development to alleviate negative impacts and maximize the positive impacts of a diagnostic label of MCI and ADRD.

PROVIDER PERCEPTIONS OF FACTORS IMPACTING COUPLES’ EMOTIONAL DISTRESS AND ADJUSTMENT TO DEMENTIA DIAGNOSES

Abstract Alzheimer’s disease and related dementias (ADRD) are increasingly common conditions that disrupt the lives of persons living with dementia and their spousal care-partners. At the time of ADRD diagnoses, many couples experience challenges that produce emotional distress and relationship strain. At present there are no interventions to address these challenges early after diagnosis to promote positive dyadic adjustment. As the first phase of a larger study, we conducted a qualitative study to elicit and systematically summarize the perspectives of ADRD medical stakeholders (e.g., neurologists, geriatricians, social workers, neuropsychologists, care coordinators) surrounding common factors impacting distress following ADRD diagnoses. Participants (n=15) were recruited from two U.S. academic medical centers and completed a 60-minute focus group or individual interview that was transcribed, deidentified, and analyzed using a rapid data analysis approach to thematic analysis. We identified findings within 3 overarching themes: reactions to diagnosis, changes in relationship roles/dynamics, and insufficient resources. Participants described couples’ distress surrounding one partner’s denial or lack of insight into the diagnosis and symptoms, experiences of loss and hopelessness, and uncertainty surrounding illness trajectory. They noticed changes in couples’ historic roles, social determinants of health, and divergent understandings and reactions to diagnosis as contributors to couples’ distress. Finally, providers observed unmet needs surrounding embedded counseling, care-planning, and financial support for current and future care needs. Most providers felt insufficiently prepared to help couples experiencing distress. Our findings underscore the importance of improving resources to address individual, interpersonal, and system-level factors that contribute to couples’ adjustment to ADRD diagnoses.

UNDERLYING CAUSES OF DEMENTIA-RELATED ANXIETY AMONG COGNITIVELY-HEALTHY INDIVIDUALS

Abstract Alzheimer’s disease and related dementias (ADRD) are prevalent, without cures, and contribute to declining functional independence. Their widespread effects make managing ADRD financially, socially, and psychologically difficult, and present challenges for the diagnosed individual as well as their family, friends, and caregivers. These features represent at least some of the reasons ADRDs are feared diagnoses. Dementia-related anxiety (DRA) is anxiety about a current or potential ADRD diagnosis. In a mixed methods study designed to identify causes of DRA, we used semi-structured interviews to assess participants’ thoughts, feelings, and reactions regarding ADRD. Participants included 50 cognitively healthy adults aged 58 to 89 (M = 70.80, SD = 6.02; 64% female). Interviews were analyzed using an inductive iterative thematic approach. All transcripts were coded by two researchers. Relying on this iterative process, we adopted and revised themes as more responses and codes were reviewed. The thematic analysis revealed participants described how the progression of symptoms would destabilize their independence, thereby undermining their identity and relationships in ways that were anxiety provoking. Participants also noted various coping strategies that help manage DRA: making care plans for the future, engaging in healthy, feeling supported by family and friends, and accepting that disappointments, including ADRD diagnoses, are simply a part of life. Results offer insight into factors that contribute to and help reduce DRA, which can be used to inform public health messaging and develop applicable and clinically relevant interventions to meet the needs of individuals experiencing DRA.

LONGITUDINAL USE TRAJECTORIES OF SEDATIVE-HYPNOTICS AND RISK FOR DEMENTIA AMONG MEDICARE BENEFICIARIES

Abstract Research suggests use of sedative-hypnotic medications (Benzodiazepines [BZDs; e.g., diazepam] and non-BZD hypnotics [e.g., zolpidem]) to be associated with incident Alzheimer’s disease and related dementias (ADRD). We identified longitudinal dose and duration use patterns of these medications and their associations with ADRD risk. This retrospective cohort study used 2016-2018 claims data from a 15% national sample of fee-for-service Medicare beneficiaries and included beneficiaries aged ≥65 years initiating use of a) BZDs only, b) non-BZDs only, or c) BZDs+non-BZDs concurrently. We excluded beneficiaries with ADRD diagnosis 6 months before and 12 months after first BZD/non-BZD prescription date. Based on average weekly diazepam milligram equivalent dose (low: &amp;lt;15, moderate: 15-30, high: &amp;gt;30), we used group-based multi-trajectory models to identify distinct trajectories of BZD/non-BZD use over 12 months after initiation (i.e., trajectory period). We estimated risk of time to first occurrence of ADRD after trajectory period associated with these trajectories using inverse propensity score weighted Cox proportional hazards models. Among 131,574 beneficiaries (mean age=74 years, 68% female, 89% White), we identified 11 trajectories (4 BZD only [78% of cohort], 4 non-BZD only [18%], and 3 concurrent users [4%]). Compared to beneficiaries with low-dose discontinuing non-BZD only use, trajectories associated with an increased risk of ADRD included: stable moderate-dose BZD use with concurrent stable low-dose non-BZD use (HR=2.28, 95%CI=1.62-3.21) and high-dose declining BZD only use (HR=1.57, 95%CI=1.26-1.96). Results highlight a need to assess not only patterns of BZD and non-BZD use alone, but also concurrent use, when considering risk for ADRD.

Testing the ‘Faith Moves Mountains model’ to increase Alzheimer’s disease awareness, detection, and diagnosis among rural, racially, and ethnically diverse older adults

Objectives Racially and ethnically diverse populations have recently contributed to the majority of rural and small-town growth. Consequently, the disproportionately high risk and prevalence of Alzheimer’s disease and related dementias (ADRD) among rural and minoritized older residents will likely increase. To address this threat, we tested the hypotheses that (1) a faith-based, resident-led approach would increase basic ADRD knowledge and diagnosis, and (2) older age, female gender, lower educational levels, and more years lived rural would predict number of referrals, new dementia diagnoses, and treatment. Methods An adaptation of Schoenberg’s Faith Moves Mountains model, previously successful in detection and management of other chronic illnesses in rural settings, guided this community-based participatory research. Local faith community members were trained as research assistants to recruit, administer surveys, conduct brief memory assessments, teach brain health strategies, and follow-up with residents. Outreaches were offered virtually during the pandemic, then in-person monthly at rotating church sites, and repeated ∼1 year later. Results This rural sample was racially and ethnically diverse (74.5% non-White), with 28% reporting eight or less years of formal education. Findings included that referrals and years lived rural were significant and positive predictors of new ADRD treatments [(b = 3.74, χ 2(1, n = 235) = 13.01, p < 0.001); (b = 0.02, χ 2(1, n = 235 = 3.93, p = 0.048)], respectively, regardless of participant characteristics. Conclusion Resident-led action research in rural, diverse, faith communities is a successful approach to increasing ADRD disease knowledge, detection, diagnosis, and treatment.

Risk of dementia among veterans experiencing homelessness and housing instability.

In the United States, nearly 85,000 Veterans experienced homelessness during 2020, and thousands more are experiencing housing instability, representing a significant proportion of the population.1 Many Veterans experiencing homelessness are aging and have complex co-occurring medical, psychiatric, and substance use disorders. Homelessness and older age put Veterans at greater risk for age-related disorders, including Alzheimer's disease and related dementias (ADRD). We examined the rate of ADRD diagnosis for Veterans experiencing homelessness and housing instability compared to a matched cohort of stably housed Veterans over a nine-year period using cox proportional hazard models. In the matched cohort, 95% (n = 88,811) of Veterans were men, and 67% (n = 59,443) were White and were on average 63 years old (SD = 10.8). Veterans with housing instability had a higher hazard of 1.53 (95% confidence interval (CI) 1.50, 1.59) for ADRD compared to Veterans without housing instability. Veterans experiencing housing instability have a substantially higher risk of receiving an ADRD diagnosis than a matched cohort of stably housed Veterans. Health systems and providers should consider cognitive screening among people experiencing housing insecurity. Existing permanent supportive housing programs should consider approaches to modify wraparound services to support Veterans experiencing ADRD.

Regional variation in diagnostic intensity of dementia among older U.S. adults: a cross‐sectional study

AbstractBackgroundAlzheimer’s disease and related dementias (ADRD) are known to be underdiagnosed; but little is understood about how the likelihood of obtaining a diagnosis varies across place or demographic subgroups. Using observed diagnosed cases from national billing data, we report variation by region, age, and race/ethnicity in newly diagnosed dementia cases taking into account underlying population risk.MethodAmong a 20% random sample of fee‐for‐service Medicare beneficiaries, we identified those who received a new ADRD diagnosis in 2019 using billing data. The rate of new ADRD diagnosis was estimated overall and by Hospital Referral Region (HRR) and stratified by age category (65‐74, 75‐84, ≥85) and by race/ethnicity. A measure of ADRD diagnosis intensity across HRRs was calculated as the observed‐to‐expected ratio (O:E ratio) of new cases; expected new ADRD cases for each HRR were estimated using Poisson regression adjusted for regional measures of education, population health (diabetes, obesity, and smoking), and diagnostic intensity for chronic illness. Among older Americans, the probability of receiving an ADRD diagnosis was estimated according to regional ADRD diagnosis intensity.Result3.0% (143,029 of 4,842,034) of older adults received a new ADRD diagnosis in 2019 and ranged from 1.7‐5.4% across HRRs (Figure 1). The unadjusted mean ADRD diagnosis rate was 2.9 per 100 and differed by age (age ≥ 85 = 8.8/100, 75‐84 = 3.4/100, and 65‐74 = 1.0/100, p&lt;.001) and race (White = 2.9/100, Black 3.4/100, and Hispanic 2.8/100, p&lt;.001). Variability across HRRs was largest among the youngest age category, Black, and Latino groups. In adjusted analyses, all the regional characteristics explained 33% of the variation in new ADRD diagnosis (pseudo‐R2 = 0.33). Adjusted for regional characteristics, the ADRD diagnosis intensity (i.e., O:E ratio) varied from 0.7 to 1.4 across HRRs overall (Figure 2) and was most variable among the youngest age category (65‐74), Black, and Latino groups. These groups also had the greatest difference in the likelihood of diagnosis if residing in low versus high ADRD diagnosis intensity (Figure 3).ConclusionThe likelihood of receiving an ADRD diagnosis varies across the U.S., particularly among those 65‐74 years of age, and Black, and Latino groups.

Location Dynamics in Northern Rural Minnesota: Barriers and Facilitators for ADRD Diagnosis and Care

AbstractBackgroundThe location dynamics of rural northern Minnesota involve shifting economic structures, demographic transitions, and diverse physical environments that affect access to Alzheimer’s Disease and Related Dementias (ADRD) diagnosis, care and health services.MethodWe conducted semi‐structured interviews with 56 key informants including health care providers (n = 7), health leaders and administrators (n = 10), social workers (n = 12), formal and informal caregivers (n = 19), and healthy older adults (n = 8) across northern Minnesota concerning the unique protective and risk factors and the socio‐cultural context of ADRD in the region. Interviews were transcribed and thematically coded in QSR NVivo using a lived experience framework.ResultOur analysis reveals that winter weather, depopulation trends, and lack of healthcare facilities and services and aspects of rural culture create multi‐faceted challenges to healthy aging and ADRD diagnosis and care. Rural residents often rely on social capital, community institutions, volunteerism, and families to compensate for the lack of medical services. Rural people without social or financial resources may have to relocate to different communities to receive care and services. This lack of access to local care influences stigma and fear of dementia diagnoses in rural areas. These experiences shape cultural understandings of ADRD, and health seeking behaviors, which can be characterized as hesitant and dismissive, creating additional challenges for community interventions.ConclusionThe location dynamics of rural northern Minnesota shape unique cultural understandings around ADRD diagnosis and care that limits the effectiveness of existing interventions and demands tailored approaches to overcome the lack of local resources, geographic distance, and winter weather constraints. Dense social networks, a culture of volunteerism, and community capacity to develop medical infrastructure are key assets used to overcome these challenges to ADRD care.

Impact of Dementia on Days at Home after Traumatic Brain Injury among Older Medicare Beneficiaries

AbstractBackgroundTraumatic brain injury (TBI) is a highly disabling event among older adults, contributing to disability in activities of daily living and elevated risk for nursing home admission. Older adults with Alzheimer’s disease and related dementias (ADRD) are more susceptible to TBI given increased fall incidence in this population, but how ADRD influences long‐term disability outcomes after TBI has been challenging to ascertain because of small sample sizes in prior work. Home time, a claims‐based measure of time spent at home and not hospitalized following a health‐related event, may aid in determining the association of ADRD and post‐TBI outcomes among older adults. Thus, the objective of this study was to examine the impact of TBI on home time among older adults with ADRD.MethodsWe conducted a retrospective cohort study using a random sample of Medicare administrative claims data for years 2010‐2018. Community‐dwelling Medicare beneficiaries aged ≥65 years hospitalized with a primary diagnosis of TBI were included and ADRD was defined at baseline (i.e. before TBI) using diagnostic codes. Home time was calculated by subtracting the number of days spent in a care environment or deceased from the total follow‐up available for each of the twelve follow‐up months post‐TBI. We modelled monthly days at home as a function of ADRD and covariates using generalized estimating equations.ResultsThere were 20,350 participants in the study, of whom 6,683 (33.8%) had a pre‐existing diagnosis of ADRD. In regression models that accounted for pre‐TBI days at home, demographic and clinical characteristics, and probability of survival, beneficiaries with ADRD spent fewer days at home following TBI compared to beneficiaries without ADRD (rate ratio 0.90; 95% confidence interval 0.89, 0.92). This disparity was equivalent to almost 50 fewer days spent at home over the year following TBI.ConclusionTBI resulted in a significant loss of home time over the year following injury, a loss markedly worse among older adults with ADRD.

Attitudes and Practices towards the use of technology‐screening tools, diagnosis, and management of cognitive impairment in primary care

AbstractBackgroundPrevious studies in the Cuban population suggest that Alzheimer’s Disease and related dementias (ADRD) are under‐diagnosed at primary care relative to population estimates. Recent interventions aimed to introduce the use of technology based cognitive assessments have been validated for primary care (e.g., Brain Health Assessment).However, the implementation of newly develop tools depends on the Primary care providers’ (PCPs) barrier and attitudes toward the diagnosis and management of patients with ADRD at a primary care level. Here we aimed to assess PCPs’ attitudes towards ADRD diagnosis, and the use of technology based cognitive assessments.Method84 PCPs were randomly selected form 10 primary care clinics. Sample size include a wide range of PCPs, including: family medicine (n = 54), neurologist (n = 2), psychiatrists(n = 13), psychologists(n = 10), clinicians (n = 3) and geriatricians (n = 2)). A questionnaire on Dementia assessment and management in primary care settings was administered to the participants. Descriptive statistics were employed for summarizing the data. Kruskal Wallis association test was utilized for determining associations between provider characteristics and outcomes.ResultsMost participants were female (n = 64, 76.2%), over 50 years old (n = 36, 52.9%) and family medicine practitioners (64.3%). The average number of patients consulted per month by PCPs were 250 (CI95% 250‐367) and over 60% of them were 55 years or older. Most of the PCPs (n = 63, 75.0%) will not refer patients with suspected ADRD if they had the training and instruments and technologies for the diagnosis at a primary care level. Lack of time (n = 59, 70.2%) and lack of confidence in their abilities (n = 68, 81.0%) were the most cited barriers for the diagnosis and management of ADRD . Around 80.0% of the interviewed practitioners considered the use of technology based cognitive assessments as important or very important tool for ADRD diagnosis. The positive attitudes of the PCPs for using technologies were correlated with the municipalities where they work (p = 0.01) and the continuous professional development of the PCPs (p = 0.03).ConclusionThere are still barriers for the diagnosis of ADRD at a primary care level. Though PCPs are willing to implement technology based cognitive assessments in their daily practice, addressing existing barriers is key for success

Impact on End‐of‐life Planning of a Care Coordination Program for persons living with dementia

AbstractBackgroundAlzheimer’s disease and related dementias (ADRD) afflict over five million persons in the U.S., and persons living with dementia (PLWD) have been shown to receive poor quality care and have worse health outcomes compared to those without ADRD. We developed a population‐based dementia care management program to support the care of PWLD in a large U.S. healthcare system.MethodsIn a large multi‐specialty medical group practice, we identified patients enrolled in a value‐based insurance program (Medicare Advantage) using the EPIC electronic health record (EHR), and eligible patients were invited to enroll in the CARES dementia care program. Patients were eligible if they had an ICD‐10 diagnosis of ADRD in the EHR problem list and/or past medical history, or currently taking an FDA‐approved medication for ADRD. We additionally included patients with ADRD who have a primary care provider in the affiliated academic health system. During an in‐person intake visit, a study‐assigned nurse practitioner (NP) engaged in advance care planning discussion with patients and caregivers and completed advance directives (AD) and Physician Order for Life Sustaining Treatment (POLST). We assessed the rate of completion of the AD and POLST pre‐program and post‐enrollment.ResultsWe enrolled 195 patients in the CARES dementia care program. After enrollment, participants increased completion of advanced directives from 27.7% to 30.8% (p = 0.25) and the POLST from 13.3% to 23.1% (p = 0.006). Of the POLST forms completed, 70.7% indicated that the patient was ‘do not attempt resuscitation’ (DNAR) (65.2% of those who completed the POLST pre‐program, 77.8% for those who completed after enrollment, p = 0.19). Among those who completed the POLST, 55.0% indicated selective medical interventions (63.6% pre‐program, 47.1% post‐enrollment, p = 0.15), 40.0% wanted full medical interventions (31.8% pre‐program, 52.9% post‐enrollment, p = 0.10), and 5.0% wanted comfort‐focused interventions (4.5% pre‐program, 5.9% post‐enrollment, p = 0.43). Trial period of nutritional supports was indicated by 69.2% (72.7% pre‐program, 64.7% post‐enrollment, p = 0.28), while 28.2% wanted no artificial treatment (27.2% pre‐program, 29.4% post‐enrollment, p = 0.45), and 2.6% wanted long‐term nutritional support (0% pre‐program, 5.9% post‐enrollment, p = 0.13).ConclusionA dementia care coordination program shows signs of increased completion of end‐of‐life planning, with the majority choosing ‘do not attempt resuscitation’ (DNAR).

Prevalence of Dementia in a Diverse Cohort of Adults with Hip Fracture

AbstractBackgroundThere is a 2.5‐fold increased risk of hip fracture for persons living with dementia compared to persons without dementia. Independently, the risk of hip fracture and Alzheimer’s Disease and Related Dementias (ADRD) increase with age and vary by sex and race and ethnicity. However, few studies have examined racial and ethnic variations in dementia prevalence among older US adults who experienced a hip fracture.MethodThis retrospective observational cohort study included adult health plan members aged ≥50y in a large Northern California healthcare system during 2000‐2019 who had a hip fracture event during follow‐up to 2021. ADRD diagnosis (ICD‐9/10) was obtained from clinical encounters within 5 years prior to and including the hip fracture hospitalization. Modified log‐Poisson regression models were performed with ADRD as the outcome and race and ethnicity as the primary predictor, adjusting for age and sex. Sensitivity analyses expanded the definition of prevalence of ADRD to include ADRD diagnoses up to 3 months after hip fracture.ResultAmong 46,622 adults with hip fracture (mean age 80.6 ± 9.9y, 69.7% female, 78.8% non‐Hispanic White (NHW) race), ADRD prevalence was 21.0% based on diagnoses prior to and during hip fracture hospitalization, increasing to 24.2% when including diagnoses within 3 months post‐hip fracture. ADRD prevalence was significantly higher in Black (29.2%), Hispanic (22.5%), and Asian (22.0%) adults compared to NHW (20.3%) adults. Expanding the definition found similar observations except no significant differences for Hispanic and Asian adults (see Figure). Adjusting for age and sex, Black (RR = 1.47, 95%CI 1.35‐1.59), Hispanic (RR = 1.15, 95%CI 1.07‐1.24) and Asian adults (RR = 1.12, 95% CI 1.04‐1.21) had greater risk of prevalent ADRD compared to NHW adults. Sensitivity analysis results were similar.ConclusionAt least 1 in 5 adults with hip fracture had diagnosed ADRD, with higher prevalence among racial and ethnic minority populations. Age‐ and sex‐adjusted risk was highest in Black adults and modestly higher in Hispanic and Asian adults. Hip fractures and ADRD are serious public health concerns leading to increased morbidity and mortality, and understanding differences among high risk groups will aid in the development of socially appropriate patient and caregiver interventions.

Racial disparities in Alzheimer’s Disease and Related Dementias (ADRD): The association between early life adversity and ADRD

AbstractBackgroundAdverse childhood experiences (ACEs) are an important public health concern that predict neuroanatomical changes in development such as decreased prefrontal cortex and hippocampal volumes, and can lead to poor health outcomes in adulthood, including cognitive impairment. Alzheimer’s disease (AD) is the most common cause of dementia, and it disproportionately affects racial and ethnic minoritized (REM) individuals. Research demonstrates that some of the mechanisms underlying these racial disparities may include differences in exposure to specific types of ACEs (i.e. parental remarriage and/or death). A significant ACE burden can lead to disruption of the hypothalamic‐pituitary adrenal (HPA) axis, our fight‐or‐flight response system to environmental threats and stressors. Growing evidence has shown an association between ACEs and the development of cognitive impairment in older adulthood, including AD and related dementias (ADRD). We do not know, however, how biomarkers related to HPA axis dysregulation in association with ACEs are correlated to ADRD biomarkers (pathology) in a nationally representative, diverse cohort of individuals.MethodsA preliminary study is being conducted to evaluate the associations between early life adversity (measured retrospectively through surveys) and ADRD in several cohorts, including the Minority Aging in Research Study (MARS) from the Rush University Alzheimer’s Disease Research Center, the Stress and Resilience in Dementia (STRIDE) cohort from the University of Wisconsin, and the Duke University Medical Center clinics using DEDUCE, an on‐line query system in MaestroCare, Duke University Hospital’s electronic medical record system. Statistical analyses will be performed using R software.ResultsPending statistical analyses.ConclusionValidation of ACEs as independent risk factors for AD and contributors to the racial disparities seen in this condition will offer new potential therapeutic targets at the molecular level, new clinical screening modalities for specific ACEs instigating cognitive decline, and public policy insights to address a history of childhood trauma in patients with a clinical diagnosis of ADRD. This is especially for those REM individuals who have historically had a delayed or missed diagnosis and have been disproportionately impacted by ADRD.The research project described is supported by the National Institute On Aging of the National Institutes of Health under Award Number P30AG072958.