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Health Affairs Takes a Deeper Look into the State of Research and Far-Reaching Implications of Alzheimer's Disease


Bethesda, MD -- Health Affairs' April issue addresses the litany of public and personal ramifications of Alzheimer's disease--the most expensive condition in the United States both in terms of real costs and the immeasurable toll on loved ones. Articles examine best practices and models of care; an overview of the disease; the effects on caregivers; and what may lie ahead for a disproportionately underfunded research community.


Support for the issue comes from Eli Lilly and Company; the Alzheimer's Association; Janssen Research & Development, LLC; and Accelerate Cure/Treatments for Alzheimer's Disease (ACT-AD).


Unnecessary hospital and emergency department (ED) visits are particularly difficult on people with Alzheimer's--and costly to the health care system--but they experience them more often than their counterparts without dementia. Zhanlian Feng of RTI International and colleagues examined Medicare claims data linked to the Health and Retirement Study to determine hospital and ED use among older people with and without dementia across community and institutional settings. They found that in the community older people with dementia were more likely to have a hospitalization or ED visit than those without dementia, and that both groups had a marked increase in health care usage near the end of life. Specifically, they found significant differences in hospitalizations and ED visits among community-dwelling residents, with 26.7 percent of dementia patients versus 18.7 percent of non-dementia residents experiencing hospitalization, and 34.5 percent versus 25.4 percent experiencing an ED visit. Differences were less pronounced among nursing home residents and tended to even out among all groups in the last year of life. The researchers suggest that policy makers consider promoting the use of alternative end-of-life options such as hospice care and providing supportive services and advance care planning to Medicare beneficiaries that can help reduce avoidable hospital-based care.


A New York City caregiver support model translates into big potential savings in Minnesota. Kirsten Hall Long of K. Long Consulting and coauthors modeled the effects of adopting the New York University Caregiver Intervention (NYUCI) program across Minnesota from 2010 to 2025 and predicted a potential direct care cost savings of $996 million to the state over the period. They also found that 19.3 percent fewer people with dementia would die in institutions during this time frame and approximately 5.0 percent more people living with dementia would remain in their homes each year after three years of program implementation. The NYUCI program provides enhanced caregiver support services consisting of six sessions of in-person counseling, encouragement to participate in a weekly support group, and ad hoc telephone counseling. The authors suggest that with widespread adoption, substantial caregiver participation, and reasonable program costs, programs like this may provide an immediate path to moderate the alarming and growing dementia-related expenditures.


Who your doctor is has always mattered. If you are a dementia patient in the hospital, what specific kind of doctor you have can also make a difference. Joan Teno of Brown University and coauthors studied rates of feeding tube insertion for hospitalized elderly people with dementia and determined that differences and changes in the types of attending physicians had a dramatic effect on the likelihood of feeding tube insertion. They found that feeding tube insertions were more common when subspecialists (11.0 percent) or a mix of doctors (15.6 percent) were overseeing care versus a hospitalist (1.6 percent) or nonhospitalist general practitioner (2.2 percent). Eating problems are common in an estimated 86 percent of people with advanced dementia. Yet the practice of using a feeding tube can conflict with family wishes for comfort care, is not necessarily associated with improved survival, and carries adverse effects. With trends continuing toward treatment by a mixture of physicians in hospitals, the authors recommend reexamining the role of the attending physician and implementing practices to ensure better coordination of care, especially for this most frail of patient populations.


Alzheimer's in African Americans is more prevalent and manifests itself differently--determining why will remain a persistent challenge without more data. Lisa L. Barnes and David A. Bennett of Rush University Medical Center provide a review of the evidence behind biologic, cultural, health systems-based factors that may be contributing to African Americans' two- to three-times higher lifetime risk of developing Alzheimer's disease when compared to non-Hispanic whites. The authors maintain that cognitive tests done over time actually indicate small or no differences in performance among these populations and that studies on risk factors have produced useful, yet insufficient, explanations of the disparities--largely due to the lack of African American participation in research studies. They offer four recommendations to advance the understanding of Alzheimer's in African Americans: 1) include African Americans without dementia in studies of Alzheimer's; 2) research institutions and academics need to be more visible and actively involved in the communities they serve; 3) study a range of risk factors and their effects on cognition over time; and 4) go beyond traditional cognitive function tests, including imaging, biomarkers, and autopsy studies, to aid in accurate diagnoses.


In addition, Health Affairs Senior Editor Jonathan S. Bor's Report from the Field provides a detailed analysis of the state of Alzheimer's research and areas of promise and challenge for the National Institutes of Health and other major research institutions.

About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically at The full text of each Health Affairs Web First paper is available free of charge to all website visitors for a one-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund. You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download our podcasts, including monthly Narrative Matters essays, on iTunes. Tap into Health Affairs content with the new iPad app.