And Related Dementias Patients Research Articles

Patterns of national emergency department utilization by fee-for-service Medicare beneficiaries with dementia.

Individuals with Alzheimer's disease and related dementias (ADRD) often face high acute care clinical utilization and costs with unclear benefits in survival or quality of life. The emergency department (ED) is frequently the site of pivotal decisions in these acute care episodes. This study uses national Medicare data to explore this population's ED utilization. Retrospective cohort study of persons aged ≥66 years enrolled in traditional Medicare with a Chronic Condition Warehouse diagnosis of dementia. Primary 1-year outcome measures included ED visits with and without hospitalization, ED visits per 100 days alive, and health-care costs. A multivariate random effects regression model (clustered by county of residence), adjusted for sociodemographics and comorbidities, examined how place of care on January 1, 2018, was associated with subsequent ED utilization. In 2018, 2,680,006 ADRD traditional Medicare patients (mean age 82.9, 64.2% female, 9.4% Black, 6.2% Hispanic) experienced a total of 3,234,767 ED visits. Over half (52.2%) of the cohort experienced one ED visit, 15.5% experienced three or more, and 37.1% of ED visits resulted in hospitalization. Compared with ADRD patients residing at home without services, the marginal difference in ED visits per 100 days alive varied by location of care. Highest differences were observed for those with hospitalizations (0.48 visits per 100 days alive, 95% confidence interval [CI] 0.47-0.49), skilled nursing facility (rehab/skilled nursing facility [SNF]) stays (0.27, 95% CI 0.27-0.28), home health stays (0.25, 95% CI 0.25-0.26), or observation stays (0.82, 95% CI 0.77-0.87). Similar patterns were observed with ED use without hospitalization and health-care costs. Persons with ADRD frequently use the ED-particularly those with recent hospitalizations, rehab/SNF stays, or home health use-and may benefit from targeted interventions during or before the ED encounters to reduce avoidable utilization and ensure goal-concordant care.

What Matters to Chinese and Korean American Dementia Caregivers: Navigating Cultural Influences in Dementia Care from Caregivers' Perspectives.

Chinese and Korean Americans are among the fastest-growing minority groups in the US but face disparities in income and limited English proficiency, leading to health inequities in Alzheimer's disease and related dementias (ADRD) care. This study aims to understand cultural influences in ADRD care from the perspectives of Chinese and Korean American caregivers to inform culturally sensitive support for caregivers in Asian immigrant populations. We conducted a study that was part of a broader project aimed at informing the cultural adaptation of the NYU Caregiver Intervention-Enhanced Support (NYUCI-ES) program specifically for Chinese and Korean American caregivers managing multiple chronic conditions. In our interviews with 14 Chinese American and 11 Korean American caregivers, we focused on how their roles as primary caregivers were influenced by cultural and family expectations, the impact of caregiving on their personal and emotional well-being, and the specific barriers they face in accessing healthcare for themselves and their relatives with dementia. Cultural beliefs and values significantly influenced the perceptions and utilization of support systems among Chinese and Korean American caregivers. Family stigma and adherence to cultural norms impacted their caregiving experiences. The study also highlighted the added burden during the pandemic and the potential benefits of telehealth and information technology in ADRD care. Developing culturally tailored, person-centered programs is crucial to meeting the unique needs of Chinese and Korean American caregivers. This research contributes to understanding and supporting this vulnerable population, promoting healthcare equity for ADRD patients and caregivers.

Understanding the Perspectives and Needs of Latinx Caregivers of Persons with Alzheimer's Disease in the Appalachians: An Interpretive Phenomenological Approach.

Alzheimer's disease and related dementias (ADRD) disproportionately impact Latinx and other communities of color in the United States. The challenges for patients with ADRD and their informal caretakers can be attributed, in part, to the gaps that exist within health care services and systems. To understand the perspectives of barriers, beliefs, knowledge, and needs for the Latinx informal caregivers that take care of relatives with ADRD in the Upstate of South Carolina, region of Appalachia. This study was approved by the GHS-Prisma Health and Clemson University IRB, Study #Pro00086707. In-depth phone interviews were conducted with a sample of Latinx informal caregivers. A descriptive and interpretive phenomenological approach was used for analysis. Participants were recruited through community partnerships with local organizations. Salient themes identified in this study included the relevance of caregiver's degree of awareness about the disease and a perspective of Alzheimer's disease as a progressive and degenerative disease. Critical moments identified encompassed challenges related to patient engagement with the outside world, their attitudes, and behaviors, as well as caregiver-related challenges with access to culturally and linguistically relevant resources needed to provide proper care. Caregivers identified several culturally relevant coping strategies used and motivators in providing care for their relatives with ADRD. Linguistically and culturally sensitive programs and resources that account for knowledge, assets, and needs of Latinx informal caregivers of ADRD patients are needed to improve the quality of care and decrease disparities in health outcomes for Latinx older adults.

Ezetimibe Lowers Risk of Alzheimer's and Related Dementias over Sevenfold, Reducing Aggregation in Model Systems by Inhibiting 14-3-3G::Hexokinase Interaction.

Numerous factors predispose to progression of cognitive impairment to Alzheimer's disease and related dementias (ADRD), most notably age, APOE(ε4) alleles, traumatic brain injury, heart disease, hypertension, obesity/diabetes, and Down's syndrome. Protein aggregation is diagnostic for neurodegenerative diseases, and may be causal through promotion of chronic neuroinflammation. We isolated aggregates from postmortem hippocampi of ADRD patients, heart-disease patients, and age-matched controls. Aggregates, characterized by high-resolution proteomics (with or without crosslinking), were significantly elevated in heart-disease and ADRD hippocampi. Hexokinase-1 (HK1) and 14-3-3G/γ proteins, previously implicated in neuronal signaling and neurodegeneration, are especially enriched in ADRD and heart-disease aggregates vs. controls (each P<0.008), and their interaction was implied by extensive crosslinking in both disease groups. Screening the hexokinase-1::14-3-3G interface with FDA-approved drug structures predicted strong affinity for ezetimibe, a benign cholesterol-lowering medication. Diverse cultured human-cell and whole-nematode models of ADRD aggregation showed that this drug potently disrupts HK1::14-3-3G adhesion, reduces disease-associated aggregation, and activates autophagy. Mining clinical databases supports drug reduction of ADRD risk, decreasing it to 0.14 overall (P<0.0001; 95% C.I. 0.06-0.34), and <0.12 in high-risk heart-disease subjects (P<0.006). These results suggest that drug disruption of the 14-3-3G::HK1 interface blocks an early "lynchpin" adhesion, prospectively reducing aggregate accrual and progression of ADRD.

ACCESS TO PREFERRED POSTACUTE CARE PATHWAYS FOR PATIENTS WITH ALZHEIMER’S DISEASE AND RELATED DEMENTIAS

Abstract Hospital-to-skilled nursing facility (SNF) transitions are fraught with coordination challenges, motivating selective investments by hospitals to improve transitional care practices with “preferred” (e.g. high-volume) SNF partners. Because these partners have some agency in which patients they admit, it is unclear whether Medicare beneficiaries with social or clinical complexities, such as individuals with Alzheimer’s disease and related dementias (ADRD) have equitable access to these preferred SNFs. To answer this question, we use a linear probability choice model to test the differential effect of a SNF’s “preferredness” on patient placement for ADRD vs non-ADRD beneficiaries. We use a 1:1 matched sample of ADRD and non-ADRD fee-for-service beneficiaries (N=76,762) to account for other primary factors affecting placement (i.e. discharging hospital, beneficiaries’ home address). After controlling for SNF characteristics, the estimated effect of a SNF being “preferred” on likelihood of placement was 12.7% lower for patients with ADRD (0.092 vs 0.103 for non-ADRD; p&amp;lt; 0.001). Simulation results suggest that, as a preferred SNF is assumed to have an increasing percentage of a hospital’s discharges, the likelihood of a patient being discharged there grows much faster for non-ADRD patients compared to those with ADRD. Our findings show that ADRD patients may have unequal access to SNFs that are receiving the most investments from hospitals in the form of transitional care improvements. Policymakers should consider systemic investments that benefit all SNF partners, not just the most preferred based on shared discharges, while also weighing the costs of dispersing these investments too broadly.

Symposium 06: Perioperative Neurocognitive Disorders With Considerations for Alzheimer’s Disease and Related Dementias

Summary AbstractLow- and high-risk surgical procedures are performed annually on more than half a million patients aged 65 and older. Yet, at least 20-35% of older patients undergoing surgery have undiagnosed signs of a mild to major neurocognitive disorder. These facts are alarming as older age, and preoperative memory/cognitive/affective vulnerabilities are significant predictors of postoperative cognitive complications such as delirium, cognitive decline, and mortality. Given the expected rate increase of neurodegenerative disorders in the populous, perioperative health care systems will face more significant numbers of individuals with undiagnosed Alzheimer’s disease and related dementias (ADRD) needing procedures with anesthesia due to severe health-related conditions (e.g., cardiac) or requesting surgeries for quality of life improvement (e.g., joint replacement). Through this symposium, attendees will learn from experts about the urgency of appreciating Perioperative Cognitive Disorders and the need for evidence-based perioperative ADRD assessment and intervention methods. Symposium speakers represent the International Society to Advance Alzheimer’s Research and Treatment’s “Perioperative Cognition and Delirium” Professional Interest Area. Lisbeth Evered, Ph.D., University of Melbourne, Australia, will begin the symposium by discussing the nomenclature for Perioperative Neurocognitive Disorders and the need to include neuropsychologists as part of the multidisciplinary diagnostic team. Robert Whittington, MD, University of California, Los Angeles, will present a bench-to-beside review of how tau protein is altered by perioperative factors and its potential relationship to cognition impairment after surgery and anesthesia. Miles Berger, M.D., Ph.D., Duke University, will present his team’s federally funded research showing how anesthesia is a stress test for the brain and the potential implications for incorporating intraoperative EEG monitoring into routine care. Kristin Hamlet, Ph.D., University of Florida, will round out the symposium by presenting a novel perioperative care environment where neuropsychologists identify at-risk undiagnosed ADRD patients before surgery for multidisciplinary care interventions. She will also highlight a cognitive “rescue” multidisciplinary intervention case. Attendees will leave the symposium with an improved understanding of Perioperative Neurocognitive Disorders and how neuropsychologists can work with other disciplines to advance evidence-based perioperative care for at-risk older adults electing surgery with anesthesia.

Leveraging natural language processing to identify social determinants of health for patients with Alzheimer’s disease and related dementias from electronic medical records

AbstractBackgroundSocial determinants of health (SDoH) have a significant impact on the well‐being of individuals with Alzheimer’s disease and related dementias (ADRD). ADRD patients from socioeconomically disadvantaged groups are generally subject to higher risks of adverse health events than those from advantaged groups. However, information related to SDoH is not collected systematically in most medical institutions. Unstructured electronic medical records (EMRs), including free‐text clinical narratives and nurse and social worker notes, may include salient information that can be used to identify individuals who may need assistance. In this study, we sought to develop a rule‐based, natural language processing (NLP) algorithm that identifies from patients’ unstructured EMRs their housing instability, transportation problems, food and medication insecurity, solitariness, and financial exploitation.MethodWe randomly selected 1,000 medical notes from Michigan Medicine between 2016 and 2019 and partitioned them into 750 notes for training and 250 notes for testing. Training notes were preprocessed by a prototype algorithm and annotated by registered nurses. We then trained the algorithm by resolving all human and machine disagreements. The post‐training NLP algorithm was evaluated on the testing notes. The most promising medical notes that found information about SDoH were social worker notes.ResultThe NLP algorithm achieved 85.3% of note‐wise accuracy. Determinant‐wise accuracy scores were 88.6% (housing), 91.1% (transportation), 86.7% (food), 92.0% (medication), 87.4% (solitariness) and 95.3% (financial exploitation). Determinant‐wise F1‐scores were 90.6% (housing), 86.9% (transportation), 91.3% (food), 95.7% (medication), 82.3% (solitariness) and 93.8% (financial exploitation).ConclusionOur NLP algorithm is a stand‐alone module that can run on real‐time EMRs and extract information about SDoH with a high level of accuracy. Findings can be used by clinicians, care managers, and social workers to pragmatically and efficiently reach out to ADRD patients who may need assistance with food, transportation, or housing. In doing this, adverse health events may be reduced among this vulnerable patient population. Future efforts will focus on making this algorithm generalizable for use at other institutions.

Predictors of 30-day readmission, mortality, and length of stay for hospitalized U.S. patients with Alzheimer’s and related dementias from 2010 to 2015

Objectives Examine predictors of clinical and resource utilization outcomes associated with Alzheimer’s disease and related dementias (ADRD), stratified by patient severity profiles. Methods Cross-sectional study of adults (30+ year old) with ADRD discharged from US hospitals to home health care (HHC) and identified from the 2010-2015 Nationwide Readmissions Database (NRD) using ICD 9th-10th codes. Outcomes of interest included 30-day hospital readmissions, in-hospital mortality, and hospital length of stay (LOS). Covariates consisted of sociodemographic and clinical variables. Multiple logistic regressions (for readmissions and mortality) and generalized linear regressions (for LOS) were used to examine associations between outcomes and study covariates, stratified by patient severity profiles. Results Of 164,598 ADRD patients, 3,848 were mild, 68,803 were moderate, 72,428 were severe, and 19,519 were extreme. The 30-day readmission rate was 3.2%, death rate was 14.5%, and LOS was 3.0 days, (95%, CI: 15.0, 17.0) to 5.0 days, (95%, CI: 18.0, 19.0), all with a p-value < 0.0001. Across outcomes and severity levels, the top predictors included number of diagnoses, gender, hospital bed size, primary and secondary diagnoses, and income size. Conclusions Severe and extreme stages of HHC discharge may lead to increased readmissions, death, LOS, and costs. Specialized care is needed to reduce these negative outcomes in the ADRD patient population.

Alzheimer's Disease and Related Dementias: Caregiver Perspectives on Hospice Re-Enrollment Following a Hospice Live Discharge.

Background: The number of individuals dying of Alzheimer's disease and related dementias (ADRDs) is steadily increasing and they represent the largest group of hospice enrollees. In 2020, 15.4% of hospice patients across the United States were discharged alive from hospice care, with 5.6% decertified due to being "no longer terminally ill." A live discharge from hospice care can disrupt care continuity, increase hospitalizations and emergency room visits, and reduce the quality of life for patients and families. Furthermore, this discontinuity may impede re-enrollment into hospice services and receipt of community bereavement services. Objectives: The aim of this study is to explore the perspectives of caregivers of adults with ADRDs around hospice re-enrollment following a live discharge from hospice. Design: We conducted semistructured interviews of caregivers of adults with ADRDs who experienced a live discharge from hospice (n = 24). Thematic analysis was used to analyze data. Results: Three-quarters of participants (n = 16) would consider re-enrolling their loved one in hospice. However, some believed they would have to wait for a medical crisis (n = 6) to re-enroll, while others (n = 10) questioned the appropriateness of hospice for patients with ADRDs if they cannot remain in hospice care until death. Conclusions: A live discharge for ADRD patients impacts caregivers' decisions on whether they will choose to re-enroll a patient who has been discharged alive from hospice. Further research and support of caregivers through the discharge process are necessary to ensure that patients and their caregivers remain connected to hospice agencies postdischarge.

Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study

BackgroundAlzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery. MethodsColorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes. Results5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001). ConclusionsThe diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.

Educational care for patients with Alzheimer’s disease and their caregivers in France: A mapping proposal

ObjectivesTo formalize a proposal for educational approach for patients with Alzheimer’s disease and related dementias (ADRD) and caregivers across existing diagnosis/care organizations and structures. MethodsThree steps:1/ identifying the existing organizations and structures that could be involved in educational care; 2/ identifying the main educational skills of interest for ADRD patients and caregivers; 3/ conducting a survey among these organizations and structures to achieve a mapping proposal of educational care. ResultsNine organizations and structures, and 29 educational skills of interest were identified for the step 3 survey. Overall, 423 organizations/structures completed the step 3 survey. Twelve of 29 educational skills were covered by 50% of organizations/structures included. The most covered skills were “Maintaining autonomy in daily living activities”, “coping with cognitive disorders”, and “coping with behavioral disorders”. ConclusionsA mapping of educational care that could be provided by the different structures and organizations involved in the ADRD care pathway was proposed regarding their missions and intervention place. Practice implicationsPolicy makers and funding bodies will need to invest in the healthcare professionals’ training about educational approach and ADRD in order to extend educational care throughout the patient's care pathway.

Medicare Hospice Policy Changes and Beneficiaries' Rate of Live Discharge and Length-of-Stay.

The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act systemized audits of long hospice stays, and the 2016 two-tier payment system decreased daily reimbursement rates after 60 days of enrollment. Both aimed to reduce long stays. Examine how live discharge rates and length of stay changed in relation to the policies. We computed monthly hospice-level percent live discharges and length of stay using 2008-2019 Medicare hospice claims. We compared prepolicies trends and postpolicies trends overall, within Alzheimer's disease and related dementias (ADRD) patients, within lung cancer patients, and stratified by hospice ownership (for-profit vs. nonprofit/government-owned). We included 10,539,912 and 10,453,025 episodes of care in the analytical samples for live discharge and length of stay analyses, respectively. Overall percent live discharges declined during the prepolicies period (-0.13 percentage-points per month, 95% CI: -0.14, -0.12), but exhibited no significant change during the postpolicies period. Trends were driven primarily by for-profits, with similar patterns within ADRD and lung cancer patients. Overall, mean length of stay increased over time, with greater rate of increase during the postpolicies period (0.41 days per month, 95% CI: 0.39, 0.42) compared to the prepolicies period (0.12 days per month, 95% CI: 0.10, 0.14). Length-of-stay increased faster among ADRD patients, but changed minimally for lung cancer patients. Live discharge rates declined significantly during the prepolicies period, but plateaued after implementation of the policies, driven by changes in for-profits. However, the policies did not reduce length of stay, which increased at faster rates, suggesting that postpolicies excess live discharges were not restricted to long-stay patients.

Healthcare Utilization and Mortality After Hospice Live Discharge Among Medicare Patients With and Without Alzheimer's Disease and Related Dementias.

Little is known about post-discharge outcomes among patients who were discharged alive from hospice. To compare healthcare utilization and mortality after hospice live discharge among Medicare patients with and without Alzheimer's disease and related dementias (ADRD). Retrospective cohort study using Medicare claims data of a 20% random sample of Medicare fee-for-service (FFS) patients. A total of 153,696 Medicare FFS patients experienced live discharge from hospice between 2014 and 2019. Two types of burdensome transition (type 1: live discharge from hospice followed by hospitalization and subsequent hospice readmission; type 2: live discharge from hospice followed by hospitalization with the patient deceased in the hospital), acute care utilization, hospice readmission, and mortality in the 30 and 180 days after live discharge and between live discharge and death. Compared with non-ADRD patients, ADRD patients were less likely to experience burdensome transitions (type 1: adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.90-0.98; type 2: aOR, 0.70; 95% CI, 0.65-0.75), more likely to have ED visits (aOR, 1.05; 95% CI, 1.01-1.09), less likely to die (aOR, 0.71; 95% CI, 0.69-0.73), and less likely to be readmitted to hospice (aOR, 0.86; 95% CI, 0.84-0.89) 30 days after live discharge. Results of 180-day post-discharge outcomes were largely consistent with results of 30-day outcomes. Among patients who died as of December 31, 2019, ADRD patients were less likely to be hospitalized (aOR, 0.88; 95% CI, 0.85-0.92) and more likely to be readmitted to hospice (aOR, 1.12; 95% CI, 1.08-1.16) between live discharge and death. Significant racial/ethnicity disparities in acute care utilization and mortality after live discharge existed in both ADRD and non-ADRD groups. ADRD patients had lower mortality, a longer survival time, a lower rate of hospitalization, and an initially lower but gradually increasing rate of hospice readmission than non-ADRD patients after hospice live discharge. These different trajectories warrant further investigation of the eligibility of their initial hospice enrollment. Black patients had significantly worse outcomes after hospice live discharge compared with White patients.

A COMPREHENSIVE ALZHEIMER’S AND DEMENTIA CARE PROGRAM (ADCP) FOR PATIENTS AND CAREGIVERS

Abstract Background Alzheimer’s and related dementias (ADRD) are progressive and associated with behavioral and psychological symptoms (BPSD) contributing to caregiver stress. We report initial impact of implementing UCLA-designed ADCP to support ADRD patients and caregivers. The program centralizes care, utilizing a nurse dementia-care specialist. Methods Prospective repeated measures of ADRD patient/caregiver dyads from 3/2021–7/2022. Measures: BPSD, ADL/IADL, cognition, and caregiver burden, distress and depression. Results Total of 154 patient/caregiver dyads enrolled to-date. 42 have been enrolled for one-year: 23 with complete data, 5 pending follow-up, 14 disenrolled (2 expired, 3 to hospice, 2 moved, 7 lost contact). For 23 patients with baseline and follow up, Neuropsychiatric Inventory Questionnaire decreased from 16.3 to 13.1 (p=0.170), Patient Health Questionnaire-9 (PHQ-9) for caregivers decreased (3.5 to 2.2, p=0.044), Montreal Cognitive Assessment decreased from 11.3 to 8.4 (p=0.045), and Dementia Burden Scale (DBS) showed nonsignificant decrease, 20.6 to 18.4 (p=0.312). Cornell Scale for Depression in Dementia was unchanged, 5.67 to 5.14 (p=0.380), and ADL and IADL decreased one year after enrollment, from 4.05 to 2.36 (p &amp;lt; 0.01) and 1.38 to 0.238 (p &amp;lt; 0.01) respectively. Conclusion Although attrition rate was high for the small sample (1/3 of dyads enrolled in the program for a year), there were improvements in some metrics for both patients and caregivers, despite the expected decline in cognitive function and ADL/IADL. As data is accrued, we anticipate it will identify patients and support resources that will be most beneficial.

UNDERSTANDING CAREGIVER PERSPECTIVES ON LIVE DISCHARGE AND RE-ENROLLMENT ONTO HOSPICE CARE

Abstract Hospice care improves end-of-life outcomes for adults with Alzheimer’s Disease and related dementias (ADRD), yet with eligibility limited to a six-month prognosis, the patient-caregiver dyad can experience a live discharge from hospice. In 2019, nearly 350,000 patients with an ADRD diagnosis received hospice services in the US, and 6.5% of hospice patients were discharged due to being ‘no longer terminally ill.’ Caregivers of adults with ADRD who experienced a live discharge (n=24) were interviewed and thematic analysis was conducted. More than half (58%) noted specific support in their caregiving roles while 46% cited feeling relief. Eleven participants were enrolled for one hospice episode, and six re-enrolled at least one time. While participants would consider re-enrolling, they are waiting for a health crisis (n=7) for eligibility, while others question the meaning of hospice for ADRD patients (n=10). Implications for policy, practice, and research to support the patient-caregiver dyad are discussed.

DYSPHAGIA FOLLOWING HOSPITALIZATION IN NURSING HOME RESIDENTS WITH ALZHEIMER’S DISEASE AND RELATED DEMENTIAS

Abstract Dysphagia frequently occurs in nursing home (NH) residents with Alzheimer’s Disease and Related Dementias (ADRD), often leading to serious health outcomes (e.g., pneumonia, malnutrition, reduced quality of life). While it is known that hospitalized NH residents with ADRD experience high rates of iatrogenic complications, dysphagia following discharge has not been examined. A retrospective cohort of all NH residents in the US (older adults aged ≥66) with advanced ADRD (Cognitive Function Scale ≥2), hospitalized between 2013-2017, and without a feeding tube or reported dysphagia on a Minimum Data Set (MDS) 3.0 assessment within 120 days prior to hospitalization was constructed. Treatment with intermittent mandatory ventilation (IMV) or non-invasive ventilation (NIV) during hospitalization and dysphagia status on the first post-hospitalization MDS was recorded. Data were analyzed using descriptive statistics and random effects multivariate logistic models that adjusted for age, gender, race/ethnicity, CFS score, ADL score, and comorbidities. Among the 805,199 residents with ADRD who survived the hospitalization and returned to the NH, new onset dysphagia occurred in 53,807 (6.7%; 95% CI 6.6-6.7) of residents. After adjustment, invasive mechanical ventilation (IMV) use was associated with increased risk of new onset of dysphagia (AOR 1.5; 95% CI 1.4-1.6) and non-invasive mechanical ventilation (NIMV) only slightly increased the risk (AOR 1.3; 95% 1.2-1.3). NH residents with ADRD are at risk for dysphagia following hospitalization. These findings emphasize the importance of swallowing evaluation and dysphagia treatment during hospitalization for ADRD patients, especially those treated with IMV or NIV, to prevent further negative health outcomes.

Neighborhood Deprivation and Mortality Risk among Medicare Beneficiaries with Alzheimer’s Disease and Related Dementia

AbstractBackgroundAlzheimer’s Disease (AD) and Related Dementias (ADRD) is a class of progressive fatal degenerative diseases that presents multiple causations and outcomes related to its biological, medical, and social determinants of health (SDoH). Studies have extensively explored biological and medical factors, however, SDoH, which is known to contribute to structural inequities in health outcomes, is understudied. We aimed to study the association between neighborhood deprivation (an important SDoH measurement of socioeconomic disadvantage), and the risk of mortality among older adults diagnosed with AD/ADRD.MethodUsing a 5% random sample of national Medicare claims data, we identified individuals newly diagnosed with ADRD in 2006‐2013. The outcome of interest was all‐cause mortality. The exposure of interest was area deprivation index (ADI), a validated neighborhood deprivation measure that incorporates factors of poverty, education, housing, and employment. ADI was spatiotemporally linked to the study cohort using 9‐digit ZIP codes and index scores were classified into 6 categories: quartiles plus the 10th and 90th percentile. We applied generalized estimation equations to model an odds ratio (OR) of mortality across the ADI categories while adjusting for demographic and clinical factors. Subgroup analyses were modeled within urban and rural areas, respectively.ResultsWe included 74,462 patients with ADRD diagnosis, with a mean age of 82 (SD: 8.2) years; 72.3% were women and 65.8% (n = 31218) died over a median follow‐up of 3.5 years. A dose‐gradient association between the ADI and all‐cause mortality was observed in the ADRD population, with the risk of mortality gradually increasing with greater deprivation (Table). The dose‐gradient association between ADI and mortality remained after stratifying by urban and rural areas. ADRD patients in rural areas had a higher mortality risk than those in urban areas (Table).ConclusionOur findings suggest neighborhood deprivation is an important risk factor of mortality among older adults with ADRD while accounting for individuals’ demographic and clinical characteristics. The current results underscore the need for the design and implementation of intervention and policy programs to address structural disparities in outcomes of ADRD patients.

One-year Medicare costs associated with delirium in older hospitalized patients with and without Alzheimer's disease dementia and related disorders.

One-year health-care costs associated with delirium in older hospitalized patients with and without Alzheimer's disease and related dementias (ADRD) have not been examined previously. Medicare costs were determined prospectively at discharge, and at 30, 90, and 365 days in a cohort (n = 311) of older adults after hospital admission. Seventy-six (24%) patients had ADRD and were more likely to develop delirium (51% vs. 24%, P < 0.001) and die within 1 year (38% vs. 21%, P = 0.002). In ADRD patients with versus without delirium, adjusted mean difference in costs associated with delirium were $34,828; most of the excess costs were incurred between 90 and 365 days (P = 0.03). In non-ADRD patients, delirium was associated with increased costs at all timepoints. Excess costs associated with delirium in ADRD patients increased progressively over 1 year, whereas in non-ADRD patients the increase was consistent across time periods. Our findings highlight the complexity of health-care costs for ADRD patients who develop delirium, a potentially preventable source of expenditures. Novel examination of health-care costs of delirium in persons with and without Alzheimer's disease and related dementias (ADRD). Increased 1-year costs of $34,828 in ADRD patients with delirium (vs. without). Increased costs for delirium in ADRD occur later during the 365-day study period. For ADRD patients, cost differences between those with and without delirium increased over 1 year. For non-ADRD patients, the parallel cost differences were consistent over time.

Alzheimer's disease medication use and adherence patterns by race and ethnicity.

We examined racial and ethnic differences in medication use for a representative US population of patients with Alzheimer's disease and related dementias (ADRD). We examined cholinesterase inhibitors and memantine initiation, non-adherence, and discontinuation by race and ethnicity, using data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Among newly diagnosed ADRD patients (n=1299), 26% filled an ADRD prescription ≤90 days and 36% ≤365 days after diagnosis. Among individuals initiating ADRD-targeted treatment (n=1343), 44% were non-adherent and 24% discontinued the medication during the year after treatment initiation. Non-Hispanic Blacks were more likely than Whites to not adhere to ADRD medication therapy (odds ratio: 1.50 [95% confidence interval: 1.07-2.09]). Initiation of ADRD-targeted medications did not vary by ethnoracial group, but non-Hispanic Blacks had lower adherence than Whites. ADRD medication non-adherence and discontinuation were substantial and may relate to cost and access to care. Initiation of anti-dementia medications among newly diagnosed Alzheimer's disease and related dementias (ADRD) patients was low in all ethnoracial groups. ADRD medication non-adherence and discontinuation were substantial and may relate to cost and access to care. Compared to Whites, Blacks and Hispanics had lower use, poorer treatment adherence, and more frequent discontinuation of ADRD medication, but when controlling for disease severity and socioeconomic factors, racial disparities diminish. Our findings demonstrate the importance of adjusting for socioeconomic characteristics and disease severity when studying medication use and adherence in ADRD patients.

Neurovascular Dysfunction in Diverse Communities With Health Disparities-Contributions to Dementia and Alzheimer's Disease.

Alzheimer’s disease and related dementias (ADRD) are an expanding worldwide crisis. In the absence of scientific breakthroughs, the global prevalence of ADRD will continue to increase as more people are living longer. Racial or ethnic minority groups have an increased risk and incidence of ADRD and have often been neglected by the scientific research community. There is mounting evidence that vascular insults in the brain can initiate a series of biological events leading to neurodegeneration, cognitive impairment, and ADRD. We are a group of researchers interested in developing and expanding ADRD research, with an emphasis on vascular contributions to dementia, to serve our local diverse community. Toward this goal, the primary objective of this review was to investigate and better understand health disparities in Alabama and the contributions of the social determinants of health to those disparities, particularly in the context of vascular dysfunction in ADRD. Here, we explain the neurovascular dysfunction associated with Alzheimer’s disease (AD) as well as the intrinsic and extrinsic risk factors contributing to dysfunction of the neurovascular unit (NVU). Next, we ascertain ethnoregional health disparities of individuals living in Alabama, as well as relevant vascular risk factors linked to AD. We also discuss current pharmaceutical and non-pharmaceutical treatment options for neurovascular dysfunction, mild cognitive impairment (MCI) and AD, including relevant studies and ongoing clinical trials. Overall, individuals in Alabama are adversely affected by social and structural determinants of health leading to health disparities, driven by rurality, ethnic minority status, and lower socioeconomic status (SES). In general, these communities have limited access to healthcare and healthy food and other amenities resulting in decreased opportunities for early diagnosis of and pharmaceutical treatments for ADRD. Although this review is focused on the current state of health disparities of ADRD patients in Alabama, future studies must include diversity of race, ethnicity, and region to best be able to treat all individuals affected by ADRD.