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Authors: Zhu, Carolyn W. | Cosentino, Stephanie | Ornstein, Katherine A. | Gu, Yian | Andrews, Howard | Stern, Yaakov

Article Type: Research Article

Abstract: Background: Few studies have examined how dementia and comorbidities may interact to affect healthcare expenditures. Objective: To examine whether effects of dementia severity on Medicare expenditures differed for individuals with different levels of comorbidities. Methods: Data are drawn from the Washington Heights-Inwood Columbia Aging Project (WHICAP). Comprehensive clinical assessments of dementia severity were systematically carried out at ∼18 month intervals. Dementia severity was measured by Clinical Dementia Rating (CDR). Comorbidities were measured by a modified Elixhauser comorbidities index. Generalized linear models examined effects of dementia severity, comorbidities, and their interactions on Medicare expenditures (1999–2010). Results: At baseline, 1,280 subjects were …dementia free (CDR = 0, 66.4%), 490 had very mild dementia (CDR = 0.5, 25.4%), 108 had mild dementia (CDR = 1, 5.6%), and 49 had moderate/severe dementia (CDR = 2/3, 2.5%). Average annual Medicare expenditures for individuals with moderate/severe dementia were more than twice as high as those who were dementia free (CDR = 0: $9,108, CDR = 0.5/1: $11,664, CDR≥2: $19,604, p  < 0.01). Expenditures were approximately 10 times higher among those with≥3 comorbidities than among those with no comorbidities ($2,612 for those with no comorbidities, to $6,109 for those with 1, $10,656 for those with 2, and $30,244 for those with≥3 comorbidities, p  < 0.001). Dementia severity was associated with higher expenditures, but comorbidities were the most important predictor of expenditures. We did not find strong interaction effects between number of comorbidities and dementia severity. Conclusions: Increasing dementia severity and higher comorbidities are associated with higher Medicare expenditures. Care of individuals with dementia should focus on management of comorbidities. Show more

Keywords: Health expenditure, Medicare, economics, comorbidities, longitudinal analysis

DOI: 10.3233/JAD-161077

Citation: Journal of Alzheimer's Disease, vol. 57, no. 1, pp. 305-315, 2017

Authors: Li, Clara | Neugroschl, Judith | Luo, Xiaodong | Zhu, Carolyn | Aisen, Paul | Ferris, Steven | Sano, Mary

Article Type: Research Article

Abstract: Background: Subjective cognitive complaint is a sensitive marker of decline. Objective: This study aimed to (1) examine reliability of subjective cognitive complaint using the Cognitive Function Instrument (CFI), and (2) assess the utility of the CFI to detect cognitive decline in non-demented elders. Methods: Data from a four-year longitudinal study at multiple Alzheimer’s Disease Cooperative Study (ADCS) sites were extracted (n  = 644). Of these, 497 had Clinical Dementia Rating (CDR) global scores of 0 and 147 had a CDR of 0.5. Mean age and education were 79.5±3.6 and 15.0±3.1 years, respectively. All participants and their study partners completed the subject …and study partner CFI yearly. Modified Mini-Mental State Exam (mMMSE) and Free and Cued Selective Reminding Test (FCSRT) were administered. Scores below the predetermined cut-off scores on either measure at annual visit were triggers for a full diagnostic evaluation. Cognitive decline was defined by the absence/presence of the trigger. Results: Three-month test retest reliability showed that inter-class coefficients for subject and study partner CFI were 0.76 and 0.78, respectively. Generalized estimating equation method revealed that both subject and study partner CFI change scores and scores from previous year were sensitive to cognitive decline in the CDR 0 group (p  < 0.05). In the CDR 0.5 group, only the study partner CFI change score predicted cognitive decline (p  < 0.05). Conclusion: Cognitive decline was predicted differentially by CDR level with subject CFI scores providing the best prediction for those with CDR 0 while study partner CFI predicted best for those at CDR 0.5. Show more

Keywords: Cognitive decline, healthy older adults, non-demented elders, subjective cognitive complaints

DOI: 10.3233/JAD-161294

Citation: Journal of Alzheimer's Disease, vol. 60, no. 2, pp. 427-437, 2017

Authors: Zhu, Carolyn W. | Gu, Yian | Kociolek, Anton J. | Fernandez, Kayri K. | Cosentino, Stephanie | Stern, Yaakov

Article Type: Research Article

Abstract: Background: Little is known regarding healthcare expenditures for patients with dementia with Lewy bodies (DLB) during the end of life. Objective: This study estimated Medicare expenditures during the last 5 years of life in a decedent sample of patients who were clinically diagnosed with Alzheimer’s disease (AD) or DLB and had autopsy confirmed diagnosis. Methods: The study included 58 participants clinically diagnosed with mild dementia at study entry (AD: n  = 44, DLB: n  = 14) and also had autopsy-confirmed diagnoses of pure AD (n  = 32), mixed AD+Lewy body (LB) (n  = 5), or pure LB (n  = 11). Total Medicare expenditures were compared …by clinical and pathology confirmed diagnosis, adjusting for sex, age at death, and patient’s cognition, function, comorbidities, and psychiatric and extrapyramidal symptoms. Results: When pathology diagnoses were not considered, predicted annualized total Medicare expenditures during the last 5 years of life were similar between clinically diagnosed AD ($7,465±1,098) and DLB ($7,783±1,803). When clinical diagnoses were not considered, predicted expenditures were substantially higher in patients with pathology confirmed mixed AD+LB ($12,005±2,455) than either pure AD ($6,173±941) or pure LB ($4,629±1,968) cases. Considering clinical and pathology diagnosis together, expenditures for patients with clinical DLB and pathology mixed AD+LB ($23,592±3,679) dwarfed other groups. Conclusion: Medicare expenditures during the last 5 years of life were substantially higher in patients with mixed AD+LB pathology compared to those with pure-AD and pure-LB pathologies, particularly in those clinically diagnosed with DLB. Results highlight the importance of having both clinical and pathology diagnoses in examining healthcare costs. Show more

Keywords: Alzheimer’s disease, clinical diagnosis, cost of care, dementia with Lewy bodies, Medicare claims, pathology confirmed diagnosis

DOI: 10.3233/JAD-221021

Citation: Journal of Alzheimer's Disease, vol. 92, no. 2, pp. 457-466, 2023

Authors: Zhu, Carolyn W. | Gu, Yian | Cosentino, Stephanie | Kociolek, Anton J. | Hernandez, Michelle | Stern, Yaakov

Article Type: Research Article

Abstract: Background: Misidentification of dementia in Medicare claims is quite common. Objective: We examined potential race/ethnic disparities in misidentification of dementia in Medicare claims in a diverse cohort of older adults who underwent careful clinical assessment. Methods: Participants were enrolled in the Washington Heights-Inwood Columbia Aging Project (WHICAP), a multiethnic, population-based, prospective study of cognitive aging in which dementia status was assessed using a rigorous clinical protocol. ICD-9-CM and ICD-10-CM diagnosis codes in all available Medicare claims (1999–2019) were compared to clinical dementia diagnosis and categorized into three mutually exclusive groups: 1) congruent-, 2) over-, and 3) under- identification during the …study period. Multinomial logistic regression model was used to examine the relationship between race (White, African American/Black, other) and ethnicity (Hispanic/Latinx, non-Hispanic/Latinx) and congruency of dementia identification after controlling for clinical (cognition, function, comorbidities) and demographic characteristics (age, sex, education), and inpatient and outpatient utilization. Results: Across all person-years, 88.4% had congruent identification of dementia compared to clinical diagnosis, in 4.1% of the times participants were over-identified with dementia, and 7.5% of the times the participants were under-identified. Rates of misidentification was higher in minority participants than in White, non-Hispanic participants. Multivariable estimation results showed that the probability of over-identification with dementia was 2.2% higher for African American/Black than White (p  = 0.05) and 2.7% higher for Hispanic participants than non-Hispanics (p  = 0.03) participants. Differences in under-identification by race/ethnicity were not statistically significant. Conclusions: African American/Black and Hispanic participants were more likely over-identified with dementia in Medicare claims. Show more

Keywords: Alzheimer’s disease, clinical diagnosis, disparities, Medicare claims

DOI: 10.3233/JAD-230584

Citation: Journal of Alzheimer's Disease, vol. 96, no. 1, pp. 359-368, 2023

Authors: Cárcamo, Jasmine | Kociolek, Anton J. | Fernández, Kayri K. | Gu, Yian | Zhu, Carolyn W. | Stern, Yaakov | Cosentino, Stephanie

Article Type: Short Communication

Abstract: To assess the predictive value of neuropsychological tests for severe dependency in Alzheimer’s disease as defined by the Equivalent Institutional Care Rating Scale, in a multiethnic, community cohort. The sample included 146 elders from the Predictors 3 cohort. Cox proportional hazard models tested the predictive value of each neuropsychological test at baseline on relative risk of meeting severe dependency. Higher semantic processing and memory test scores at baseline were associated with lower risk of meeting severe dependency in the adjusted Cox models. The integrity of semantic processing and memory abilities in dementia appears to predict time to severe functional dependency.

Keywords: Alzheimer’s disease, cognition, dementia, memory, neuropsychological tests

DOI: 10.3233/JAD-210019

Citation: Journal of Alzheimer's Disease, vol. 83, no. 2, pp. 539-544, 2021

Authors: Stallard, Eric | Kociolek, Anton | Jin, Zhezhen | Ryu, Hyunnam | Lee, Seonjoo | Cosentino, Stephanie | Zhu, Carolyn | Gu, Yian | Fernandez, Kayri | Hernandez, Michelle | Kinosian, Bruce | Stern, Yaakov

Article Type: Research Article

Abstract: Background: The major aims of the three Predictors Studies have been to further our understanding of Alzheimer’s disease (AD) progression sufficiently to predict the length of time from disease onset to major disease outcomes in individual patients with AD. Objectives: To validate a longitudinal Grade of Membership (L-GoM) prediction algorithm developed using clinic-based, mainly white patients from the Predictors 2 Study in a statistically representative community-based sample of Hispanic (N = 211) and non-Hispanic (N = 62) older adults (with 60 males and 213 females) from the Predictors 3 Study and extend the algorithm to mild cognitive impairment (MCI). Methods: The L-GoM model was …applied to data collected at the initial Predictors 3 visit for 150 subjects with AD and 123 with MCI. Participants were followed annually for up to seven years. Observed rates of survival and need for full-time care (FTC) were compared to those predicted by the algorithm. Results: Initial MCI/AD severity in Predictors 3 was substantially higher than among clinic-based AD patients enrolled at the specialized Alzheimer’s centers in Predictors 2. The observed survival and need for FTC followed the L-GoM model trajectories in individuals with MCI or AD, except for N = 32 subjects who were initially diagnosed with AD but reverted to a non-AD diagnosis on follow-up. Conclusion: These findings indicate that the L-GoM model is applicable to community-dwelling, multiethnic older adults with AD. They extend the use of the model to the prediction of outcomes for MCI. They also justify release of our L-GoM calculator at this time. Show more

Keywords: Alzheimer’s disease, custodial care, dementia progression, life tables, mild cognitive impairment, mortality determinants, patient-specific modeling, prognostic factors, survival, validation

DOI: 10.3233/JAD-220811

Citation: Journal of Alzheimer's Disease, vol. 95, no. 1, pp. 93-117, 2023

Authors: Li, Clara | Neugroschl, Judith | Zhu, Carolyn W. | Aloysi, Amy | Schimming, Corbett A. | Cai, Dongming | Grossman, Hillel | Martin, Jane | Sewell, Margaret | Loizos, Maria | Zeng, Xiaoyi | Sano, Mary

Article Type: Review Article

Abstract: Mobile technologies are becoming ubiquitous in the world, changing the way we communicate and provide patient care and services. Some of the most compelling benefits of mobile technologies are in the areas of disease prevention, health management, and care delivery. For all the advances that are occurring in mobile health, its full potential for older adults is only starting to emerge. Yet, existing mobile health applications have design flaws that may limit usability by older adults. The aim of this paper is to review barriers and identify knowledge gaps where more research is needed to improve the accessibility of mobile …health use in aging populations. The same observations might apply to those who are not elderly, including individuals suffering from severe mental or medical illnesses. Show more

Keywords: Design considerations, mHealth, mobile health, mobile technology, older adults

DOI: 10.3233/JAD-200485

Citation: Journal of Alzheimer's Disease, vol. 79, no. 1, pp. 1-8, 2021

Authors: Sewell, Margaret C. | Neugroschl, Judith | Umpierre, Mari | Chin, Shehan | Zhu, Carolyn W. | Velasco, Nelly | Gonzalez, Sabrina | Acabá-Berrocal, Alexandra | Bianchetti, Luca | Silva, Gabriela | Collazo, Alma | Sano, Mary

Article Type: Research Article

Abstract: Background: Latinx elders are underrepresented in dementia research. In a previous study we assessed research attitudes in urban minority elders and found a significant minority expressed neutral to negative attitudes relating to trust, safety, and personal responsibility to help research. Objective: To assess the impact of a composite intervention on attitudes toward research and research participation among elderly Latinx. The intervention was a collaboratively produced research participation video shown during presentations with our elderly community advisory board (CAB) as co-presenters. Methods: The video was created by the ADRC and CAB. All senior center attendees were eligible to participate. Afterwards, the …Research Attitudes Questionnaire (RAQ) and a brief questionnaire on the impact of the video were administered. Using Wilcoxon Rank Sum Tests, Chi Square, and OLS regressions, RAQ responses were compared to those from a historical cohort from similar centers. Results: 74 in the “Historical Cohort 1” and 104 in “Intervention Cohort 2” were included. RAQ total score was higher in Cohort 2 than Cohort 1 (28.5 versus 26.1, p  < 0.05) after controlling for age, education, and country of origin. In response to the question “Has the video influenced your willingness and interest to participate in research”, 88.7%of the participants in Cohort 2 reported being “more” or “much more” interested in research. Conclusion: Tailoring community research recruitment programs to include relatable peers using novel recruitment techniques may have positive implications for improving enrollment of diverse elderly individuals in research. Show more

Keywords: Attitudes towards research, diversity, elder minorities, minorities in research, research participation

DOI: 10.3233/JAD-210027

Citation: Journal of Alzheimer's Disease, vol. 82, no. 2, pp. 771-779, 2021