OBJECTIVES: To evaluate the association between neighborhood walkability and depression in older adults.
DESIGN: Cross‐sectional analysis using data from Adult Changes in Thought (ACT), a ...prospective, longitudinal cohort study.
SETTING: King County, Washington.
PARTICIPANTS: Seven hundred forty randomly selected men and women aged 65 and older, cognitively intact, living in the same home for at least 2 years.
MEASUREMENTS: Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale. The Walkable and Bikable Communities Project provided objective data predicting the probability of walking at least 150 minutes per week in a particular neighborhood. ACT data were linked at the individual level via a geographic information system to this walkability score using buffer radii of 100, 500, and 1,000 meters around the subject's home. Multiple regression analysis tests were conducted for associations between the buffer‐specific neighborhood walkability score and depressive symptoms.
RESULTS: There was a significant association between neighborhood walkability and depressive symptoms in men when adjusted for individual‐level factors of income, physical activity, education, smoking status, living alone, age, ethnicity, and chronic disease. The odds ratio for the interquartile range (25th to 75th percentile) of walkability score was 0.31 to 0.33 for the buffer radii (P=.02), indicating a protective association with neighborhood walkability. This association was not significant in women.
CONCLUSION: This study demonstrates a significant association between neighborhood walkability and depressive symptoms in older men. Further research on the effects of neighborhood walkability may inform community‐level mental health treatment and focus depression screening in less‐walkable areas.
Abstract Declines in heart disease and stroke mortality rates are conventionally attributed to reductions in cigarette smoking, recognition and treatment of hypertension and diabetes, effective ...medications to improve serum lipid levels and to reduce clot formation, and general lifestyle improvements. Recent evidence implicates these and other cerebrovascular factors in the development of a substantial proportion of dementia cases. Analyses were undertaken to determine whether corresponding declines in age-specific prevalence and incidence rates for dementia and cognitive impairment have occurred in recent years. Data spanning 1 or 2 decades were examined from community-based epidemiological studies in Minnesota, Illinois, and Indiana, and from the Health and Retirement Study, which is a national survey. Although some decline was observed in the Minnesota cohort, no statistically significant trends were apparent in the community studies. A significant reduction in cognitive impairment measured by neuropsychological testing was identified in the national survey. Cautious optimism appears justified.
As the patient-centered medical home model emerges as a key vehicle to improve the quality of health care and to control costs, the experience of Seattle-based Group Health Cooperative with its ...medical home pilot takes on added importance. This paper examines the effects of the medical home prototype on patients' experiences, quality, burnout of clinicians, and total costs at twenty-one to twenty-four months after implementation. The results show improvements in patients' experiences, quality, and clinician burnout through two years. Compared to other Group Health clinics, patients in the medical home experienced 29 percent fewer emergency visits and 6 percent fewer hospitalizations. We estimate total savings of $10.3 per patient per month twenty-one months into the pilot. We offer an operational blueprint and policy recommendations for adoption in other health care settings.
We estimated dementia incidence rates, life expectancies with and without dementia, and percentage of total life expectancy without dementia.
We studied 3605 members of Group Health (Seattle, WA) ...aged 65 years or older who did not have dementia at enrollment to the Adult Changes in Thought study between 1994 and 2008. We estimated incidence rates of Alzheimer's disease and dementia, as well as life expectancies with and without dementia, defined as the average number of years one is expected to live with and without dementia, and percentage of total life expectancy without dementia.
Dementia incidence increased through ages 85 to 89 years (74.2 cases per 1000 person-years) and 90 years or older (105 cases per 1000 person-years). Life expectancy without dementia and percentage of total life expectancy without dementia decreased with age. Life expectancy with dementia was longer in women and people with at least a college degree. Percentage of total life expectancy without dementia was greater in younger age groups, men, and those with more education.
Efforts to delay onset of dementia, if successful, would likely benefit older adults of all ages.
BACKGROUND:Although one third of Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans, there is limited information about the cost of treating Alzheimer disease and related dementias ...(ADRD) in these settings.
OBJECTIVE:The objective of this study was to estimate direct health care costs attributable to ADRD among older adults within a large MA plan.
RESEARCH DESIGN:A retrospective cohort design was used to estimate direct total, outpatient, inpatient, ambulatory pharmacy, and nursing home costs for 3 years before and after an incident ADRD diagnosis for 927 individuals diagnosed with ADRD relative to a sex-matched and birth year-matched set of 2945 controls.
SUBJECT:Adults 65 years of age and older enrolled in the Kaiser Permanente Washington MA plan and the Adult Changes in Thought (ACT) Study, a prospective longitudinal cohort study of ADRD and brain aging.
MEASURES:Data on monthly health service use obtained from health system electronic medical records for the period 1992–2012.
RESULTS:Total monthly health care costs for individuals with ADRD are statistically greater (P<0.05) than controls beginning in the third month before diagnosis and remain significantly greater through the eighth month following diagnosis. Greater total health costs are driven by significantly (P<0.05) greater nursing home costs among individuals diagnosed with ADRD beginning in the third month prediagnosis. Although total costs were no longer significantly greater at 8 months following diagnosis, nursing home costs remained higher for the people with dementia through the 3 years postdiagnosis we analyzed.
CONCLUSION:Greater total health care costs among individuals with ADRD are primarily driven by nursing home costs.
Resilience to Alzheimer's disease is an uncommon combination of high disease burden without dementia that offers valuable insights into limiting clinical impact. Here we assessed 43 research ...participants meeting stringent criteria, 11 healthy controls, 12 resilience to Alzheimer's disease and 20 Alzheimer's disease with dementia and analyzed matched isocortical regions, hippocampus, and caudate nucleus by mass spectrometry-based proteomics. Of 7115 differentially expressed soluble proteins, lower isocortical and hippocampal soluble Aβ levels is a significant feature of resilience when compared to healthy control and Alzheimer's disease dementia groups. Protein co-expression analysis reveals 181 densely-interacting proteins significantly associated with resilience that were enriched for actin filament-based processes, cellular detoxification, and wound healing in isocortex and hippocampus, further supported by four validation cohorts. Our results suggest that lowering soluble Aβ concentration may suppress severe cognitive impairment along the Alzheimer's disease continuum. The molecular basis of resilience likely holds important therapeutic insights.
IMPORTANCE: Modifiable risk factors are hypothesized to account for 30% to 40% of dementia; yet, few trials have demonstrated that risk-reduction interventions, especially multidomain, are ...efficacious. OBJECTIVE: To determine if a personalized, multidomain risk reduction intervention improves cognition and dementia risk profile among older adults. DESIGN, SETTING, AND PARTICIPANTS: The Systematic Multi-Domain Alzheimer Risk Reduction Trial was a randomized clinical trial with a 2-year personalized, risk-reduction intervention. A total of 172 adults at elevated risk for dementia (age 70-89 years and with ≥2 of 8 targeted risk factors) were recruited from primary care clinics associated with Kaiser Permanente Washington. Data were collected from August 2018 to August 2022 and analyzed from October 2022 to September 2023. INTERVENTION: Participants were randomly assigned to the intervention (personalized risk-reduction goals with health coaching and nurse visits) or to a health education control. MAIN OUTCOMES AND MEASURES: The primary outcome was change in a composite modified Neuropsychological Test Battery; preplanned secondary outcomes were change in risk factors and quality of life (QOL). Outcomes were assessed at baseline and 6, 12, 18, and 24 months. Linear mixed models were used to compare, by intention to treat, average treatment effects (ATEs) from baseline over follow-up. The intervention and outcomes were initially in person but then, due to onset of the COVID-19 pandemic, were remote. RESULTS: The 172 total participants had a mean (SD) age of 75.7 (4.8) years, and 108 (62.8%) were women. After 2 years, compared with the 90 participants in the control group, the 82 participants assigned to intervention demonstrated larger improvements in the composite cognitive score (ATE of SD, 0.14; 95% CI, 0.03-0.25; P = .02; a 74% improvement compared with the change in the control group), better composite risk factor score (ATE of SD, 0.11; 95% CI, 0.01-0.20; P = .03), and improved QOL (ATE, 0.81 points; 95% CI, −0.21 to 1.84; P = .12). There were no between-group differences in serious adverse events (24 in the intervention group and 23 in the control group; P = .59), but the intervention group had greater treatment-related adverse events such as musculoskeletal pain (14 in the intervention group vs 0 in the control group; P < .001). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, a 2-year, personalized, multidomain intervention led to modest improvements in cognition, dementia risk factors, and QOL. Modifiable risk-reduction strategies should be considered for older adults at risk for dementia. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03683394
OBJECTIVES
Early recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly ...half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)‐based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule eRADAR).
DESIGN
Retrospective cohort study.
SETTING
Kaiser Permanente Washington (KPWA), an integrated healthcare delivery system.
PARTICIPANTS
A total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples.
MEASUREMENTS
EHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills).
RESULTS
Overall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31‐predictor model included markers of dementia‐related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic = .78; 95% confidence interval CI = .76‐.81) and validation (C statistic = .81; 95% CI = .78‐.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia.
CONCLUSION
The eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103–111, 2019
Introduction
We estimate the spending attributable to Alzheimer's disease and related dementias (ADRD) to the United States government for the first 5 years post‐diagnosis.
Methods
Using data from ...the Health and Retirement Study matched to Medicare and Medicaid claims, we identify a retrospective cohort of adults with a claims‐based ADRD diagnosis along with matched controls.
Results
The costs attributable to ADRD are $15,632 for traditional Medicare and $8833 for Medicaid per dementia case over the first 5 years after diagnosis. Seventy percent of Medicare costs occur in the first 2 years; Medicaid costs are concentrated among the longer‐lived beneficiaries who are more likely to need long‐term care and become Medicaid eligible.
Discussion
Because the distribution of the incremental costs varies over time and between insurance programs, when interventions occur and the effect on the disease course will have implications for how much and which program reaps the benefits.
Hypertension is an important risk factor for Alzheimer's disease (AD) and all‐cause dementia. The mechanisms underlying this association are unclear. Hypertension may be associated with AD ...neuropathological changes (ADNC), but reports are sparse and inconsistent. This systematic review included 15 autopsy studies (n = 5879) from observational cohorts. Studies were highly heterogeneous regarding populations, follow‐up duration, hypertension operationalization, neuropathological methods, and statistical analyses. Hypertension seems associated with higher plaque and tangle burden, but results are inconsistent. Four studies (n = 3993/5879; 68%), reported clear associations between hypertension and ADNC. Another four suggested that antihypertensive medication may protect against ADNC. Larger studies with longer follow‐up reported the strongest relationships. Our findings suggest a positive association between hypertension and ADNC, but effects may be modest, and possibly attenuate with higher hypertension age and antihypertensive medication use. Investigating interactions among plaques, tangles, cerebrovascular pathology, and dementia may be key in better understanding hypertension's role in dementia development.
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