Sunday, August 18, 2024

Where a patient lives may be the biggest factor for a dementia diagnosis

A University of Michigan study found significant regional differences in the likelihood of receiving a dementia diagnosis in the United States, which could have profound implications for accessing new treatments for Alzheimer's disease and other forms of dementia. The research found that the percentage of people diagnosed with dementia each year varies widely across regions, with particularly stark differences for those aged 66 to 74 and individuals who are Black or Hispanic.

The study, published in Alzheimer's & Dementia: The Journal of the Alzheimer's Association, suggests that where a person lives may play a more significant role in whether they receive a dementia diagnosis than individual risk factors. According to the findings, someone in one region of the U.S. could be twice as likely to be diagnosed with dementia as someone in another region.

Julie Bynum, M.D., a U-M Health geriatrician and lead author of the study, emphasized the need to address these disparities. "These findings go beyond demographic and population-level differences in risk and indicate that there are health system-level differences that could be targeted and remediated," said Bynum in a statement. She noted that the variation in diagnosis rates could be due to differences in health care practices, patient knowledge, and care-seeking behaviors.

The study analyzed data from 4.8 million Medicare beneficiaries aged 66 and older in 2019, focusing on "diagnostic intensity" across 306 hospital referral regions (HRRs). Researchers found that while nearly 7 million Americans currently have a dementia diagnosis, many more likely have symptoms but remain undiagnosed. Access to advanced dementia treatments, including new medications and diagnostic tests, requires a formal diagnosis.

The study found that the prevalence of diagnosed dementia ranged from 4% to 14% across HRRs, with new diagnoses in 2019 ranging from 1.7% to 5.4%. After adjusting for various factors, including education level, smoking rates, obesity, and diabetes, researchers calculated that people in low-intensity areas were 28% less likely to be diagnosed with dementia, while those in high-intensity areas were 36% more likely.

The concentration of dementia diagnoses was highest in the southern U.S., but this pattern shifted once researchers accounted for other risk factors. Bynum suggested that the variation could stem from differences in clinical practices, such as how frequently primary care physicians screen for dementia or the availability of specialists.

Bynum called for increased efforts to ensure early identification of cognitive issues, especially in younger Medicare populations. She also encouraged individuals to advocate for themselves to receive cognitive screenings, which are covered by Medicare during annual wellness visits.

Bynum highlighted Medicare's recent GUIDE model for dementia care as a potential avenue for improving care coordination and access. This new model incentivizes clinical practices to provide better dementia care and offer 24/7 access to trained providers.


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Sunday, July 7, 2024

FDA approves new treatment for Alzheimer’s disease

Alzheimer’s disease currently affects more than 6.5 million Americans. The irreversible, progressive brain disorder slowly destroys memory, thinking skills, and overtime, the ability to carry out simple tasks. Even though the specific causes of the disease are not fully known, traits of Alzheimer’s are seen through changes in the brain, including amyloid beta plaques and neurofibrillary. These changes result in the loss of neurons and their connections, affecting a person’s ability to remember, think, and speak.

Recently, the US Food and Drug Administration approved Kisunla (donanemabazbt), an injection for the treatment of Alzheimer’s disease. The organization said the new treatment should be used in patients with mild cognitive impairment or at the mild dementia stage of the disease. Kisunla should also be administered as an intravenous infusion every four weeks.

The efficacy of the treatment was studied in a double-blind, placebo-controlled, parallel-group study in patients with Alzheimer’s disease. Before the start of the study, patients had confirmed presence of amyloid pathology and mild cognitive impairment or mild dementia stage of disease. The study population had a mean age of 73 years, with a range of 59 to 86 years. 57% of patients were female, 91% were White, 6% were Asian, 4% were Hispanic or Latino, and 2% were Black.

For the first three doses, 1,736 patients were randomized 1:1 to receive 700 mg of Kisunla every four weeks and then 1,400 mg every four weeks or placebo for a total of up to 72 weeks. The treatment was switched to placebo based at Weeks 24, 52, and 76 on a prespecified reduction in amyloid levels measured by positron emission tomography (PET).

Patients who were treated with Kisunla showed a significant reduction in clinical decline on the Integrated Alzheimer’s Disease Rating Scale (iADRS), the Alzheimer’s Disease Assessment Scale-Cognitive subscale (ADAS-Cog13), and the Alzheimer’s Disease Cooperative Study – instrumental Activities of Daily Living scale (ADCS-iADL), compared to placebo at Week 76. Patients with Kisunla also demonstrated a significant reduction in clinical decline on the Clinical Dementia Rating Scale, compared to placebo at Week 76.

While Kisunla has been approved, it’s safety information is important to note. When prescribed, the treatment comes with a boxed warning for amyloid-related imaging abnormalities (ARIA). ARIA presents itself as temporary swelling in areas of the brain, usually resolving over time. It also is accompanied by small spots of bleeding in or on the surface of the brain. Typically, ARIA does not have symptoms.

The most common side effects of Kisunla were ARIA and headache. The full prescribing information about Kisunla and its risks can be found here.


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Saturday, July 6, 2024

New dementia cost model looks to lower financial toll for patients, families

Researchers from the University of Southern California (USC) are building a dementia cost model that will generate comprehensive national and annual estimates of the cost of dementia. With a five-year, $8.2 million federal grant from the National Institute of Aging, the new model could benefit patients and families by assisting families living with dementia by planning their budgets and support needs. It could also inform treatment and caregiving options, as well as shape health care policy.

Currently, the costs attributed with dementia drastically hurt families, draining their savings and causing caregivers to leave their jobs. In the US, the condition is an economic burden, with total health care and long-term care costs for individuals with Alzheimer’s or other dementias projecting to reach $360 billion this year. The Alzheimer Association even projects that this total will reach nearly $1 trillion by 2050.

Project advisor Maria Aranda, a professor at the USC Suzanne Dworak-Peck School of Social Work, said, “Other consequences may include caregivers’ lower retirement savings or limited ability to send their children to college. In turn, this leads to an intergenerational transmission of inequality and financial vulnerability for families of persons with dementia.”

The new model, known as a “dynamic microsimulation model,” will incorporate several data sets, including data from CMS. It will also account for costs across a range of disease stages, such as those acquired by the person living with dementia, their care partners and care givers, and their payers. Additionally, the model’s estimates will adjust for prevention and treatment innovations.

“Once you factor in the social costs of Alzheimer’s — how it affects family, caregivers and others — you quickly realize it is not just an illness but a social epidemic,” Dana Goldman, co-leader of the research team, said. “This project will help amplify the importance of finding treatments that forestall the devastation.”

USC Viterbi scientists will design an interface in the model, which will be available to the public and user-friendly. Researchers will be able to calculate numerous factors that affect dementia patients and their families, like the social and economic impact of drugs that treat the neuropsychiatric symptoms associated with advance dementia. This will keep patients out of hospitals and emergency rooms.

Interestingly, the tool may be able to measure cost savings provided by a new drug, Leqembi, delaying by two months the expense of 24-hour care.

Julie Zissimopoulous, a professor at the USC Price School of Public Policy and head leader of the project, said she and her research team want to know about the future implications of the drug, including its efficacy in patients overtime, particularly for 10 to 20 years.

“Leqembi is a great example,” Zissimopoulous said. “It’s a new FDA-approved treatment for early-stage Alzheimer’s; we have data from clinical trials that informs patients and the health care providers about safety and efficacy. But these data are not informative about the other outcomes patients and their families care about including quality of life impacts that may result from this slowing of cognitive decline. And we want to know about not just the 18 months of the clinical trial, but we want to know about them for 10 years, for 20 years.”

With this new infrastructure, researchers hope it’ll further understanding of dementia progression and how to delay its symptoms.

“Once you factor in the social costs of Alzheimer’s — how it affects family, caregivers and others — you quickly realize it is not just an illness but a social epidemic,” Goldman said. “This project will help amplify the importance of finding treatments that forestall the devastation.”


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Tuesday, May 28, 2024

The untold cost of caregiving: We all have a role to play

There is a memory from my medical school days that has stuck with me for decades. It’s one I’ve shared often and may have played a hand in my professional path. I came home for a medical school break and was enjoying a visit with my grandparents. We were sitting around the dining room table as we had many times, but this time was different. My grandfather’s Alzheimer’s disease symptoms had progressed since my last visit. He was a silent bystander to our family conversation that day, until, without warning, he slammed his fist on table with such force that everything shook. He stood up, agitated and upset, and ran out the front door. I followed him as he wandered the neighborhood. Eventually, I was able to bring him back inside. This was a marked change from the quiet, gentle man I had known. Although I would learn more about the progression of Alzheimer’s disease symptoms, that day, I was sure of one thing. I turned to my grandmother and said, “you can’t do this by yourself anymore.” She had been caring for my grandfather all on her own for many years with little support. Shortly after, my grandfather was moved to long-term care.

Nearly half of caregivers in the U.S. who provide care for an older adult do so for someone living with Alzheimer's disease or dementia. As America ages, these numbers are expected to grow exponentially. During my decades of experience working with people who live with Alzheimer’s disease I’ve seen first-hand the detrimental impact this condition has on the family and caregivers. The impact is especially hard on the “sandwich generation,” a term describing people who are navigating the trifecta of caring for a loved one, juggling a career, and the pressures of parenting children of their own. The complexities of care, financial burden, and human toll it takes for someone to care for people suffering from Alzheimer’s disease are staggering. Worse, these challenges go largely unnoticed and unsupported by resources in our communities.

Half of sandwich generation caregivers caring for loved ones with Alzheimer’s disease or dementia feel as though they are drowning and unprepared for the role, according to a new survey conducted by Wakefield Research and sponsored by Otsuka America Pharmaceutical. Nearly two-thirds (65%) of caregivers surveyed say that their role is more stressful than any job they’ve held in the past. They have paid a heavy price, with caregiving taking a toll on nearly every aspect of their lives, putting their finances, mental health, and jobs on the line. The impact is even greater among sandwich generation caregivers with 72% reporting they have had to cut back on spending for necessities such as food, tapping into retirement or personal savings, or cut back on their own medical care expenses.

Despite the heavy load they are carrying, two thirds (66%) of Alzheimer’s disease and dementia caregivers report feeling undervalued by society, believing society values career over caregiving.

Alzheimer’s disease and dementia caregivers shoulder a heavy burden, struggling to manage it all, every day. Undeniably, being a family caregiver is not a responsibility that is chosen; it is circumstance and obligation that most, if not all, family caregivers, are thrust into. But that doesn’t make them any less worthy of support for the vital role they play. There are, of course, silver linings. Mixed in with the stress of this role, the majority (55%) of caregivers surveyed describe their role as the most important responsibility they’ve ever had. Seeing these numbers and reflecting on my own experiences, it’s clear family caregivers are lacking tangible, practical resources to help navigate hard moments. One in nine Americans aged 65 and older has Alzheimer’s disease, and millions of families in our country will be affected by Alzheimer’s disease at one point. Alzheimer’s disease and dementia are still not approached with the same priority and urgency as our physical health. Working at a company that recognizes the challenging and critical role family caregivers play for people living with Alzheimer’s disease has affirmed for me what’s possible when we all work together to raise awareness for the needs of caregivers. In November, Otsuka announced a corporate caregiver commitment, deepening the company’s work in advocating for visibility and support of caregivers, providing tangible tools to address their needs and to make a meaningful impact in their lives. The company is also introducing caregiver benefits to Otsuka employees. It has prompted me to think about what could be achieved if all come together to address the caregiver crisis, which will continue to grow as the population ages.

We have the potential to improve the future for caregivers if we all do our part. Caregivers shouldn’t have to live in crisis to do the most vital tasks in our society. My hope is our government officials will use their platforms to ensure caregivers are protected and supported. My ask of my peers in the medical community and fellow leaders in health care is that we commit to work together to ignite greater awareness for the gaps in support that have left Alzheimer’s disease caregivers in our country struggling to care for their loved one, often at the expense of their health. As for the rest of us, we all know a caregiver. The next time you speak to them, ask them how they’re doing. Ask them what they’re going through. The more we understand their challenges and needs, the more we can understand where they need support and the value they bring.

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