@article {13511, title = {Pre-Analytical Variables Influencing Stability of Blood-Based Biomarkers of Neuropathology.}, journal = {Journal of Alzheimer{\textquoteright}s Disease}, year = {Forthcoming}, abstract = {

BACKGROUND: Sample collection and preanalytical protocols may significantly impact the results of large-scale epidemiological studies incorporating blood-based biomarkers of neuropathology.

OBJECTIVE: To evaluate the stability and assay variability of several blood-based biomarkers of neuropathology for common preanalytical conditions.

METHODS: We collected serum and plasma samples from 41 participants and evaluated the effect of processing delay of up to 72 h when stored at 4oC, three freeze-thaw cycles, and a combination of 48-h processing delay when stored at 4oC and three freeze-thaw cycles on biomarker stability. Using the Simoa assay (Quanterix Inc.), we measured amyloid-β 40 (Aβ40), amyloid-β 42 (Aβ42), neurofilament light (NfL), glial fibrillary acidic protein (GFAP), and phosphorylated tau 181 (p-tau-181).

RESULTS: We found that Aβ40 and Aβ42 levels significantly decreased after a 24-h processing delay in both plasma and serum samples, and a single freeze-thaw cycle (p < 0.0001). Nevertheless, serum Aβ42/40 ratio remained stable with a processing delay up to 48 h while plasma Aβ42/40 ratio showed only small but significant increase with a delay up to 72 h. Both plasma and serum GFAP and NfL levels were only modestly affected by processing delay and freeze-thaw cycles. Plasma p-tau-181 levels notably increased with a 24-, 48-, and 72-h processing delay, but remained stable in serum. Intra-individual variation over two weeks was minimal for all biomarkers and their levels were substantially lower in serum when compared with plasma.

CONCLUSION: These results suggest that standardizing preanalytical variables will allow robust measurements of biomarkers of neuropathology in population studies.

}, keywords = {Alzheimer, amyloid-β, blood-based biomarkers, pre-analytical variables, Simoa assay, stability}, issn = {1875-8908}, doi = {10.3233/JAD-230384}, author = {Panikkar, Daniel and Vivek, Sithara and Crimmins, Eileen and Jessica Faul and Kenneth M. Langa and Bharat Thyagarajan} } @article {9969, title = {Paths into sepsis: Trajectories of presepsis healthcare use.}, journal = {Annals of the American Thoracic Society}, volume = {16}, year = {2019}, month = {2019 Jan}, pages = {116-123}, abstract = {

RATIONALE: Sepsis is a leading cause of death and disability whose heterogeneity is often cited as a key impediment to translational progress.

OBJECTIVES: To test the hypothesis that there are consequential and significant differences in sepsis outcomes that result from differences in a patient{\textquoteright}s clinical course leading up to sepsis hospitalization.

METHODS: We conducted an observational cohort study of U.S. Health and Retirement Study (HRS) participants in Medicare (1998-2012) and U.S. Department of Veterans Affairs beneficiaries (2009). Using latent profile analysis, we identified patient subtypes based on trajectory of presepsis healthcare facility use. Subtypes were identified in the derivation cohort (1,512 sepsis hospitalizations among earlier HRS participants), then validated them in two additional cohorts (1,992 sepsis hospitalizations among later HRS participants; 32,525 sepsis hospitalizations among U.S. Department of Veterans Affairs beneficiaries). We measured the association between presepsis path and 90-day mortality using chi-square tests and multivariable logistic regression.

RESULTS: We identified three subtypes: low use of inpatient healthcare facilities, comprising 84\% of the derivation cohort; rising use, 12\%; and high use, 4\%. The shape and distribution of presepsis trajectories were similar in all three cohorts. In the derivation cohort, 90-day mortality differed by presepsis trajectory as follows: 38\% (low use), 63\% (rising use), and 48\% (high use) (P < 0.001). This association persisted in the validation cohorts (P < 0.001 for each). The rising use class remained an independent predictor of mortality after adjustment for potential confounders, including detailed physiologic data.

CONCLUSIONS: In national cohorts of patients with sepsis, we have shown that several distinct paths into sepsis exist. These paths, identified by trajectories of presepsis healthcare use, are predictive of 90-day mortality.

}, keywords = {Hospitalization, Risk Factors, Sepsis}, issn = {2325-6621}, doi = {10.1513/AnnalsATS.201806-391OC}, author = {Hallie C Prescott and Alicia G Carmichael and Kenneth M. Langa and Gonzalez, Richard and Theodore J Iwashyna} } @article {9562, title = {Association of a Negative Wealth Shock With All-Cause Mortality in Middle-aged and Older Adults in the United States.}, journal = {JAMA}, volume = {319}, year = {2018}, pages = {1341-1350}, abstract = {

Importance: A sudden loss of wealth-a negative wealth shock-may lead to a significant mental health toll and also leave fewer monetary resources for health-related expenses. With limited years remaining to regain lost wealth in older age, the health consequences of these negative wealth shocks may be long-lasting.

Objective: To determine whether a negative wealth shock was associated with all-cause mortality during 20 years of follow-up.

Design, Setting, and Participants: The Health and Retirement Study, a nationally representative prospective cohort study of US adults aged 51 through 61 years at study entry. The study population included 8714 adults, first assessed for a negative wealth shock in 1994 and followed biennially through 2014 (the most recent year of available data).

Exposures: Experiencing a negative wealth shock, defined as a loss of 75\% or more of total net worth over a 2-year period, or asset poverty, defined as 0 or negative total net worth at study entry.

Main Outcomes and Measures: Mortality data were collected from the National Death Index and postmortem interviews with family members. Marginal structural survival methods were used to account for the potential bias due to changes in health status that may both trigger negative wealth shocks and act as the mechanism through which negative wealth shocks lead to increased mortality.

Results: There were 8714 participants in the study sample (mean [SD] age at study entry, 55 [3.2] years; 53\% women), 2430 experienced a negative wealth shock during follow-up, 749 had asset poverty at baseline, and 5535 had continuously positive wealth without shock. A total of 2823 deaths occurred during 80 683 person-years of follow-up. There were 30.6 vs 64.9 deaths per 1000 person-years for those with continuously positive wealth vs negative wealth shock (adjusted hazard ratio [HR], 1.50; 95\% CI, 1.36-1.67). There were 73.4 deaths per 1000 person-years for those with asset poverty at baseline (adjusted HR, 1.67; 95\% CI, 1.44-1.94; compared with continuously positive wealth).

Conclusions and Relevance: Among US adults aged 51 years and older, loss of wealth over 2 years was associated with an increased risk of all-cause mortality. Further research is needed to better understand the possible mechanisms for this association and determine whether there is potential value for targeted interventions.

}, keywords = {Mortality, NDI, Wealth Shocks}, issn = {1538-3598}, doi = {10.1001/jama.2018.2055}, author = {Lindsay R Pool and Sarah A. Burgard and Belinda L Needham and Michael R. Elliott and Kenneth M. Langa and Carlos F. Mendes de Leon} } @article {9006, title = {The Hispanic paradox: Race/ethnicity and nativity, immigrant enclave residence and cognitive impairment among older US adults.}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, pages = {1085-1091}, abstract = {Hispanics, and particularly foreign-born Mexican Americans, have been shown to fare better across a range of health outcomes than might be expected given the generally higher levels of socioeconomic disadvantage in this population, a phenomena termed the "Hispanic Paradox". Previous research on social disparities in cognitive aging, however, has been unable to address both race/ethnicity and nativity (REN) in a nationally-representative sample of US adults leaving unanswered questions about potentially "paradoxical" advantages of Mexican ethnic-origins and the role of nativity, socioeconomic status (SES), and enclave residence. We employ biennial assessments of cognitive functioning to study prevalent and incident cognitive impairment (CI) within the three largest US REN groups: US-born non-Hispanic whites (US-NHW), US-born non-Hispanic blacks (US-NHB), US-born Mexican Americans (US-MA), and foreign-born Mexican Americans (FB-MA). Data come from a nationally-representative sample of community-dwelling older adults in the Health and Retirement Study linked with the 2000 Census and followed over 10~years (N~=~8,433). Large disadvantages in prevalent and incident CI were observed for all REN minorities respective to US-born non-Hispanic whites. Individual and neighborhood SES accounted substantially for these disadvantages and revealed an immigrant advantage: FB-MA odds of prevalent CI were about half those of US-NHW and hazards of incident CI were about half those of US-MA. Residence in an immigrant enclave was protective of prevalent CI among FB-MA. The findings illuminate important directions for research into the sources of cognitive risk and resilience and provide guidance about CI screening within the increasingly diverse aging US population.}, keywords = {Cognitive Ability, Racial/ethnic differences, Socioeconomic factors, Women and Minorities}, issn = {1532-5415}, doi = {10.1111/jgs.14806}, author = {Margaret M Weden and Jeremy Miles and Esther M Friedman and Jos{\'e} J Escarce and Peterson, Christine and Kenneth M. Langa and Regina A Shih} } @article {9245, title = {Late mortality after acute hypoxic respiratory failure.}, journal = {Thorax}, year = {2017}, abstract = {

BACKGROUND: Acute hypoxic respiratory failure (AHRF) is associated with significant acute mortality. It is unclear whether later mortality is predominantly driven by pre-existing comorbid disease, the acute inciting event or is the result of AHRF itself.

METHODS: Observational cohort study of elderly US Health and Retirement Study (HRS) participants in fee-for-service Medicare (1998-2012). Patients hospitalised with AHRF were matched 1:1 to otherwise similar adults who were not currently hospitalised and separately to patients hospitalised with acute inciting events (pneumonia, non-pulmonary infection, aspiration, trauma, pancreatitis) that may result in AHRF, here termed at-risk hospitalisations. The primary outcome was late mortality-death in the 31 days to 2 years following hospital admission.

RESULTS: Among 15 075 HRS participants, we identified 1268 AHRF and 13 117 at-risk hospitalisations. AHRF hospitalisations were matched to 1157 non-hospitalised adults and 1017 at-risk hospitalisations. Among patients who survived at least 30 days, AHRF was associated with a 24.4\% (95\%CI 19.9\% to 28.9\%, p<0.001) absolute increase in late mortality relative to adults not currently hospitalised and a 6.7\% (95\%CI 1.7\% to 11.7\%, p=0.01) increase relative to adults hospitalised with acute inciting event(s) alone. At-risk hospitalisation explained 71.2\% of the increased odds of late mortality, whereas the development of AHRF itself explained 28.8\%. Risk for death was equivalent to at-risk hospitalisation beyond 90 days, but remained elevated for more than 1 year compared with non-hospitalised controls.

CONCLUSIONS: In this national sample of older Americans, approximately one in four survivors with AHRF had a late death not explained by pre-AHRF health status. More than 70\% of this increased risk was associated with hospitalisation for acute inciting events, while 30\% was associated with hypoxemic respiratory failure.

}, keywords = {Health Shocks, Mortality, Respiratory Disease}, issn = {1468-3296}, doi = {10.1136/thoraxjnl-2017-210109}, author = {Hallie C Prescott and Sjoding, Michael W and Kenneth M. Langa and Theodore J Iwashyna and Daniel F McAuley} } @article {8905, title = {The Relationship of Obesity to Hospice Use and Expenditures: A Cohort Study.}, journal = {Annals of Internal Medicine}, year = {2017}, month = {2017 Feb 07}, abstract = {

Background: Obesity complicates medical, nursing, and informal care in severe illness, but its effect on hospice use and Medicare expenditures is unknown.

Objective: To describe the associations between body mass index (BMI) and hospice use and Medicare expenditures in the last 6 months of life.

Design: Retrospective cohort.

Setting: The HRS (Health and Retirement Study).

Participants: 5677 community-dwelling Medicare fee-for-service beneficiaries who died between 1998 and 2012.

Measurements: Hospice enrollment, days enrolled in hospice, in-home death, and total Medicare expenditures in the 6 months before death. BMI was modeled as a continuous variable with a quadratic functional form.

Results: For decedents with BMI of 20 kg/m2, the predicted probability of hospice enrollment was 38.3\% (95\% CI, 36.5\% to 40.2\%), hospice duration was 42.8 days (CI, 42.3 to 43.2 days), probability of in-home death was 61.3\% (CI, 59.4\% to 63.2\%), and total Medicare expenditures were $42~803 (CI, $41~085 to $44~521). When BMI increased to 30 kg/m2, the predicted probability of hospice enrollment decreased by 6.7 percentage points (CI, -9.3 to -4.0 percentage points), hospice duration decreased by 3.8 days (CI, -4.4 to -3.1 days), probability of in-home death decreased by 3.2 percentage points (CI, -6.0 to -0.4 percentage points), and total Medicare expenditures increased by $3471 (CI, $955 to $5988). For morbidly obese decedents (BMI >=40 kg/m2), the predicted probability of hospice enrollment decreased by 15.2 percentage points (CI, -19.6 to -10.9 percentage points), hospice duration decreased by 4.3 days (CI, -5.7 to -2.9 days), and in-home death decreased by 6.3 percentage points (CI, -11.2 to -1.5 percentage points) versus decedents with BMI of 20 kg/m2.

Limitation: Baseline data were self-reported, and the interval between reported BMI and time of death varied.

Conclusion: Among community-dwelling decedents in the HRS, increasing obesity was associated with reduced hospice use and in-home death and higher Medicare expenditures in the last 6 months of life.

Primary Funding Source: Robert Wood Johnson Foundation Clinical Scholars Program.

}, keywords = {Hospice, Medicare/Medicaid/Health Insurance, Obesity, Older Adults}, issn = {1539-3704}, doi = {10.7326/M16-0749}, author = {Tamara B Harris and Byhoff, Elena and Chithra R Perumalswami and Kenneth M. Langa and Alexi A Wright and Jennifer J Griggs} } @article {8547, title = {Late mortality after sepsis: propensity matched cohort study.}, journal = {BMJ}, volume = {353}, year = {2016}, month = {2016 May 17}, pages = {i2375}, abstract = {

OBJECTIVES: ~To determine whether late mortality after sepsis is driven predominantly by pre-existing comorbid disease or is the result of sepsis itself.

DEIGN: ~Observational cohort study.

SETTING: ~US Health and Retirement Study.

PARTICIPANTS: ~960 patients aged >=65 (1998-2010) with fee-for-service Medicare coverage who were admitted to hospital with sepsis. Patients were matched to 777 adults not currently in hospital, 788 patients admitted with non-sepsis infection, and 504 patients admitted with acute sterile inflammatory conditions.

MAIN OUTCOME MEASURES: ~Late (31 days to two years) mortality and odds of death at various intervals.

RESULTS: ~Sepsis was associated with a 22.1\% (95\% confidence interval 17.5\% to 26.7\%) absolute increase in late mortality relative to adults not in hospital, a 10.4\% (5.4\% to 15.4\%) absolute increase relative to patients admitted with non-sepsis infection, and a 16.2\% (10.2\% to 22.2\%) absolute increase relative to patients admitted with sterile inflammatory conditions (P<0.001 for each comparison). Mortality remained higher for at least two years relative to adults not in hospital.

CONCLUSIONS: ~More than one in five patients who survives sepsis has a late death not explained by health status before sepsis.

}, keywords = {Aged, Aged, 80 and over, Case-Control Studies, Cause of Death, Female, Hospital Mortality, Hospitalization, Humans, Longitudinal Studies, Male, Medicare, Propensity Score, Prospective Studies, Sepsis, Time Factors, United States}, issn = {1756-1833}, doi = {10.1136/bmj.i2375}, url = {https://www.ncbi.nlm.nih.gov/pubmed/27189000}, author = {Hallie C Prescott and Osterholzer, John J and Kenneth M. Langa and Angus, Derek C and Theodore J Iwashyna} } @article {8287, title = {Antidepressant Use and Cognitive Decline: The Health and Retirement Study.}, journal = {Am J Med}, volume = {128}, year = {2015}, month = {2015 Jul}, pages = {739-46}, publisher = {128}, abstract = {

BACKGROUND: Depression is associated with cognitive impairment and dementia, but whether treatment for depression with antidepressants reduces the risk for cognitive decline is unclear. We assessed the association between antidepressant use and cognitive decline over 6 years.

METHODS: Participants were 3714 adults aged 50 years or more who were enrolled in the nationally representative Health and Retirement Study and had self-reported antidepressant use. Depressive symptoms were assessed using the 8-item Center for Epidemiologic Studies Depression Scale. Cognitive function was assessed at 4 time points (2004, 2006, 2008, 2010) using a validated 27-point scale. Change in cognitive function over the 6-year follow-up period was examined using linear growth models, adjusted for demographics, depressive symptoms, comorbidities, functional limitations, and antidepressant anticholinergic activity load.

RESULTS: At baseline, cognitive function did not differ significantly between the 445 (12.1\%) participants taking antidepressants and those not taking antidepressants (mean, 14.9\%; 95\% confidence interval, 14.3-15.4 vs mean, 15.1\%; 95\% confidence interval, 14.9-15.3). During the 6-year follow up period, cognition declined in both users and nonusers of antidepressants, ranging from -1.4 change in mean score in those with high depressive symptoms and taking antidepressants to -0.5 change in mean score in those with high depressive symptoms and not taking antidepressants. In adjusted models, cognition declined in people taking antidepressants at the same rate as those not taking antidepressants. Results remained consistent across different levels of baseline cognitive function, age, and duration of antidepressant use (prolonged vs short-term).

CONCLUSIONS: Antidepressant use did not modify the course of 6-year cognitive change in this nationally representative sample.

}, keywords = {Age Distribution, Aged, Aged, 80 and over, Antidepressive Agents, Cognition, Cross-Sectional Studies, Depressive Disorder, Female, Follow-Up Studies, Geriatric Assessment, Humans, Incidence, Male, Middle Aged, Reference Values, Risk Assessment, Sex Distribution, Surveys and Questionnaires, United States}, issn = {1555-7162}, doi = {10.1016/j.amjmed.2015.01.007}, author = {Jane S Saczynski and Allison B Rosen and Ryan J McCammon and Zivin, Kara and Susan E. Andrade and Kenneth M. Langa and Sandeep Vijan and Paul A Pirraglia and Becky A. Briesacher} } @article {8660, title = {Factors associated with cognitive evaluations in the United States.}, journal = {Neurology}, volume = {84}, year = {2015}, month = {2015 Jan 06}, pages = {64-71}, abstract = {

OBJECTIVE: We aimed to explore factors associated with clinical evaluations for cognitive impairment among older residents of the United States.

METHODS: Two hundred ninety-seven of 845 subjects in the Aging, Demographics, and Memory Study (ADAMS), a nationally representative community-based cohort study, met criteria for dementia after a detailed in-person study examination. Informants for these subjects reported whether or not they had ever received a clinical cognitive evaluation outside of the context of ADAMS. Among subjects with dementia, we evaluated demographic, socioeconomic, and clinical factors associated with an informant-reported clinical cognitive evaluation using bivariate analyses and multivariable logistic regression.

RESULTS: Of the 297 participants with dementia in ADAMS, 55.2\% (representing about 1.8 million elderly Americans in 2002) reported no history of a clinical cognitive evaluation by a physician. In a multivariable logistic regression model (n = 297) controlling for demographics, physical function measures, and dementia severity, marital status (odds ratio for currently married: 2.63 [95\% confidence interval: 1.10-6.35]) was the only significant independent predictor of receiving a clinical cognitive evaluation among subjects with study-confirmed dementia.

CONCLUSIONS: Many elderly individuals with dementia do not receive clinical cognitive evaluations. The likelihood of receiving a clinical cognitive evaluation in elderly individuals with dementia associates with certain patient-specific factors, particularly severity of cognitive impairment and current marital status.

}, keywords = {Aged, Aged, 80 and over, Cognition Disorders, Cohort Studies, Dementia, Female, Humans, Logistic Models, Male, Marital Status, Multivariate Analysis, Neuropsychological tests, Severity of Illness Index, United States}, issn = {1526-632X}, doi = {10.1212/WNL.0000000000001096}, url = {http://www.neurology.org/cgi/doi/10.1212/WNL.0000000000001096}, author = {Vikas Kotagal and Kenneth M. Langa and Brenda L Plassman and Gwenith G Fisher and Bruno J Giordani and Robert B Wallace and James F. Burke and David C Steffens and Mohammed U Kabeto and Roger L. Albin and Norman L Foster} } @article {8260, title = {Hospitalization Type and Subsequent Severe Sepsis.}, journal = {Am J Respir Crit Care Med}, volume = {192}, year = {2015}, month = {2015 Sep 01}, pages = {581-8}, publisher = {192}, abstract = {

RATIONALE: Hospitalization is associated with microbiome perturbation (dysbiosis), and this perturbation is more severe in patients treated with antimicrobials.

OBJECTIVES: To evaluate whether hospitalizations known to be associated with periods of microbiome perturbation are associated with increased risk of severe sepsis after hospital discharge.

METHODS: We studied participants in the U.S. Health and Retirement Study with linked Medicare claims (1998-2010). We measured whether three hospitalization types associated with increasing severity of probable dysbiosis (non-infection-related hospitalization, infection-related hospitalization, and hospitalization with Clostridium difficile infection [CDI]) were associated with increasing risk for severe sepsis in the 90 days after hospital discharge. We used two study designs: the first was a longitudinal design with between-person comparisons and the second was a self-controlled case series design using within-person comparison.

MEASUREMENTS AND MAIN RESULTS: We identified 43,095 hospitalizations among 10,996 Health and Retirement Study-Medicare participants. In the 90 days following non-infection-related hospitalization, infection-related hospitalization, and hospitalization with CDI, adjusted probabilities of subsequent admission for severe sepsis were 4.1\% (95\% confidence interval [CI], 3.8-4.4\%), 7.1\% (95\% CI, 6.6-7.6\%), and 10.7\% (95\% CI, 7.7-13.8\%), respectively. The incidence rate ratio (IRR) of severe sepsis was 3.3-fold greater during the 90 days after hospitalizations than during other observation periods. The IRR was 30\% greater after an infection-related hospitalization versus a non-infection-related hospitalization. The IRR was 70\% greater after a hospitalization with CDI than an infection-related hospitalization without CDI.

CONCLUSIONS: There is a strong dose-response relationship between events known to result in dysbiosis and subsequent severe sepsis hospitalization that is not present for rehospitalization for nonsepsis diagnoses.

}, keywords = {Aged, Aged, 80 and over, Anti-Bacterial Agents, Clostridioides difficile, Dysbiosis, Enterocolitis, Pseudomembranous, Female, Hospitalization, Humans, Incidence, Information Storage and Retrieval, Longitudinal Studies, Male, Medicare, Patient Readmission, Retrospective Studies, Risk Factors, Sepsis, United States}, issn = {1535-4970}, doi = {10.1164/rccm.201503-0483OC}, author = {Hallie C Prescott and Dickson, R. P. and Mary A M Rogers and Kenneth M. Langa and Lwashyna, T. J.} } @article {8188, title = {Readmission diagnoses after hospitalization for severe sepsis and other acute medical conditions.}, journal = {JAMA}, volume = {313}, year = {2015}, note = {10.1001/jama.2015.1410}, month = {2015 Mar 10}, pages = {1055-7}, publisher = {313}, keywords = {Acute Disease, Hospitalization, Humans, Patient Readmission, Sepsis}, issn = {1538-3598}, doi = {10.1001/jama.2015.1410}, url = {http://dx.doi.org/10.1001/jama.2015.1410}, author = {Hallie C Prescott and Kenneth M. Langa and Theodore J Iwashyna} } @article {8046, title = {Cohort Profile: the Health and Retirement Study (HRS).}, journal = {Int J Epidemiol}, volume = {43}, year = {2014}, month = {2014 Apr}, pages = {576-85}, publisher = {43}, abstract = {

The Health and Retirement Study (HRS) is a nationally representative longitudinal survey of more than 37 000 individuals over age 50 in 23 000 households in the USA. The survey, which has been fielded every 2 years since 1992, was established to provide a national resource for data on the changing health and economic circumstances associated with ageing at both individual and population levels. Its multidisciplinary approach is focused on four broad topics-income and wealth; health, cognition and use of healthcare services; work and retirement; and family connections. HRS data are also linked at the individual level to administrative records from Social Security and Medicare, Veteran{\textquoteright}s Administration, the National Death Index and employer-provided pension plan information. Since 2006, data collection has expanded to include biomarkers and genetics as well as much greater depth in psychology and social context. This blend of economic, health and psychosocial information provides unprecedented potential to study increasingly complex questions about ageing and retirement. The HRS has been a leading force for rapid release of data while simultaneously protecting the confidentiality of respondents. Three categories of data-public, sensitive and restricted-can be accessed through procedures described on the HRS website (hrsonline.isr.umich.edu).

}, keywords = {Aged, Female, Genetic Predisposition to Disease, Health Status, Humans, Longitudinal Studies, Male, Mental Health, Middle Aged, Physical Fitness, Retirement, United States}, issn = {1464-3685}, doi = {10.1093/ije/dyu067}, author = {Amanda Sonnega and Jessica Faul and Mary Beth Ofstedal and Kenneth M. Langa and John W R Phillips and David R Weir} } @article {7996, title = {Development and validation of a brief dementia screening indicator for primary care.}, journal = {Alzheimers Dement}, volume = {10}, year = {2014}, note = {Export Date: 21 April 2014 Source: Scopus Article in Press}, month = {2014 Nov}, pages = {656-665.e1}, publisher = {10}, abstract = {

BACKGROUND: Detection of "any cognitive impairment" is mandated as part of the Medicare annual wellness visit, but screening all patients may result in excessive false positives.

METHODS: We developed and validated a brief Dementia Screening Indicator using data from four large, ongoing cohort studies (the Cardiovascular Health Study [CHS]; the Framingham Heart Study [FHS]; the Health and Retirement Study [HRS]; the Sacramento Area Latino Study on Aging [SALSA]) to help clinicians identify a subgroup of high-risk patients to target for cognitive screening.

RESULTS: The final Dementia Screening Indicator included age (1 point/year; ages, 65-79 years), less than 12~years of education (9 points), stroke (6 points), diabetes mellitus (3 points), body mass index less than 18.5~kg/m(2) (8 points), requiring assistance with money or medications (10 points), and~depressive symptoms (6 points). Accuracy was good across the cohorts (Harrell{\textquoteright}s C statistic: CHS, 0.68; FHS, 0.77; HRS, 0.76; SALSA, 0.78).

CONCLUSIONS: The Dementia Screening Indicator is a simple tool that may be useful in primary care settings to identify high-risk patients to target for cognitive screening.

}, keywords = {Aged, Cohort Studies, Dementia, Female, Humans, Male, Mass Screening, Predictive Value of Tests, Primary Health Care, Proportional Hazards Models, Risk Assessment}, issn = {1552-5279}, doi = {10.1016/j.jalz.2013.11.006}, url = {http://www.scopus.com/inward/record.url?eid=2-s2.0-84893186546andpartnerID=40andmd5=3b617dce24578e022db389d90ad9ddd1}, author = {Deborah E Barnes and Alexa S. Beiser and Anne Lee and Kenneth M. Langa and Alain Koyama and Sarah R Preis and John Neuhaus and Ryan J McCammon and Kristine Yaffe and Seshadri, Sudha and Mary Haan and David R Weir} } @article {8115, title = {Increased 1-year healthcare use in survivors of severe sepsis.}, journal = {Am J Respir Crit Care Med}, volume = {190}, year = {2014}, note = {Times Cited: 1}, month = {2014 Jul 01}, pages = {62-9}, publisher = {190}, abstract = {

RATIONALE: Hospitalizations for severe sepsis are common, and a growing number of patients survive to hospital discharge. Nonetheless, little is known about survivors{\textquoteright} post-discharge healthcare use.

OBJECTIVES: To measure inpatient healthcare use of severe sepsis survivors compared with patients{\textquoteright} own presepsis resource use and the resource use of survivors of otherwise similar nonsepsis hospitalizations.

METHODS: This is an observational cohort study of survivors of severe sepsis and nonsepsis hospitalizations identified from participants in the Health and Retirement Study with linked Medicare claims, 1998-2005. We matched severe sepsis and nonsepsis hospitalizations by demographics, comorbidity burden, premorbid disability, hospitalization length, and intensive care use.

MEASUREMENTS AND MAIN RESULTS: Using Medicare claims, we measured patients{\textquoteright} use of inpatient facilities (hospitals, long-term acute care hospitals, and skilled nursing facilities) in the 2 years surrounding hospitalization. Severe sepsis survivors spent more days (median, 16 [interquartile range, 3-45] vs. 7 [0-29]; P < 0.001) and a higher proportion of days alive (median, 9.6\% [interquartile range, 1.4-33.8\%] vs. 1.9\% [0.0-7.9\%]; P < 0.001) admitted to facilities in the year after hospitalization, compared with the year prior. The increase in facility-days was similar for nonsepsis hospitalizations. However, the severe sepsis cohort experienced greater post-discharge mortality (44.2\% [95\% confidence interval, 41.3-47.2\%] vs. 31.4\% [95\% confidence interval, 28.6-34.2\%] at 1 year), a steeper decline in days spent at home (difference-in-differences, -38.6 d [95\% confidence interval, -50.9 to 26.3]; P < 0.001), and a greater increase in the proportion of days alive spent in a facility (difference-in-differences, 5.4\% [95\% confidence interval, 2.8-8.1\%]; P < 0.001).

CONCLUSIONS: Healthcare use is markedly elevated after severe sepsis, and post-discharge management may be an opportunity to reduce resource use.

}, keywords = {Aged, Female, Health Facilities, Humans, Insurance Claim Review, Long-term Care, Male, Medical Record Linkage, Medicare, Mortality, Outcome Assessment, Health Care, Patient Readmission, Prospective Studies, Sepsis, Skilled Nursing Facilities, Survivors, United States}, issn = {1535-4970}, doi = {10.1164/rccm.201403-0471OC}, author = {Hallie C Prescott and Kenneth M. Langa and Liu, Vincent and Gabriel J. Escobar and Theodore J Iwashyna} } @article {7967, title = {Neuropsychiatric disorders and potentially preventable hospitalizations in a prospective cohort study of older Americans.}, journal = {J Gen Intern Med}, volume = {29}, year = {2014}, note = {Export Date: 6 August 2014 Article in Press}, month = {2014 Oct}, pages = {1362-71}, publisher = {29}, abstract = {

BACKGROUND: The relative contributions of depression, cognitive impairment without dementia (CIND), and dementia to the risk of potentially preventable hospitalizations in older adults are not well understood.

OBJECTIVE(S): To determine if depression, CIND, and/or dementia are each independently associated with hospitalizations for ambulatory care-sensitive conditions (ACSCs) and rehospitalizations within 30 days after hospitalization for pneumonia, congestive heart failure (CHF), or myocardial infarction (MI).

DESIGN: Prospective cohort study.

PARTICIPANTS: Population-based sample of 7,031 Americans > 50 years old participating in the Health and Retirement Study (1998-2008).

MAIN MEASURES: The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. The Modified Telephone Interview for Cognitive Status and/or ICD-9-CM dementia diagnoses were used to identify baseline CIND or dementia. Primary outcomes were time to hospitalization for an ACSC and presence of a hospitalization within 30 days after hospitalization for pneumonia, CHF, or MI.

KEY RESULTS: All five categories of baseline neuropsychiatric disorder status were independently associated with increased risk of hospitalization for an ACSC (depression alone: Hazard Ratio [HR]: 1.33, 95\% Confidence Interval [95\%CI]: 1.18, 1.52; CIND alone: HR: 1.25, 95\%CI: 1.10, 1.41; dementia alone: HR: 1.32, 95\%CI: 1.12, 1.55; comorbid depression and CIND: HR: 1.43, 95\%CI: 1.20, 1.69; comorbid depression and dementia: HR: 1.66, 95\%CI: 1.38, 2.00). Depression (Odds Ratio [OR]: 1.37, 95\%CI: 1.01, 1.84), comorbid depression and CIND (OR: 1.98, 95\%CI: 1.40, 2.81), or comorbid depression and dementia (OR: 1.58, 95\%CI: 1.06, 2.35) were independently associated with increased odds of rehospitalization within 30 days after hospitalization for pneumonia, CHF, or MI.

CONCLUSIONS: Depression, CIND, and dementia are each independently associated with potentially preventable hospitalizations in older Americans. Older adults with comorbid depression and cognitive impairment represent a particularly at-risk group that could benefit from targeted interventions.

}, keywords = {Aged, Aged, 80 and over, Cognition Disorders, Cohort Studies, Dementia, depression, Female, Hospitalization, Humans, Male, Mental Disorders, Prospective Studies, Risk Factors, United States}, issn = {1525-1497}, doi = {10.1007/s11606-014-2916-8}, author = {Dimitry S Davydow and Zivin, Kara and Wayne J Katon and Gregory M Pontone and Lydia Chwastiak and Kenneth M. Langa and Theodore J Iwashyna} } @article {8053, title = {Obesity and 1-year outcomes in older Americans with severe sepsis.}, journal = {Crit Care Med}, volume = {42}, year = {2014}, note = {Export Date: 21 April 2014 Source: Scopus Article in Press}, month = {2014 Aug}, pages = {1766-74}, publisher = {42}, abstract = {

OBJECTIVES: Although critical care physicians view obesity as an independent poor prognostic marker, growing evidence suggests that obesity is, instead, associated with improved mortality following ICU admission. However, this prior empirical work may be biased by preferential admission of obese patients to ICUs, and little is known about other patient-centered outcomes following critical illness. We sought to determine whether 1-year mortality, healthcare utilization, and functional outcomes following a severe sepsis hospitalization differ by body mass index.

DESIGN: Observational cohort study.

SETTING: U.S. hospitals.

PATIENTS: We analyzed 1,404 severe sepsis hospitalizations (1999-2005) among Medicare beneficiaries enrolled in the nationally representative Health and Retirement Study, of which 597 (42.5\%) were normal weight, 473 (33.7\%) were overweight, and 334 (23.8\%) were obese or severely obese, as assessed at their survey prior to acute illness. Underweight patients were excluded a priori.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Using Medicare claims, we identified severe sepsis hospitalizations and measured inpatient healthcare facility use and calculated total and itemized Medicare spending in the year following hospital discharge. Using the National Death Index, we determined mortality. We ascertained pre- and postmorbid functional status from survey data. Patients with greater body mass indexes experienced lower 1-year mortality compared with nonobese patients, and there was a dose-response relationship such that obese (odds ratio = 0.59; 95\% CI, 0.39-0.88) and severely obese patients (odds ratio = 0.46; 95\% CI, 0.26-0.80) had the lowest mortality. Total days in a healthcare facility and Medicare expenditures were greater for obese patients (p < 0.01 for both comparisons), but average daily utilization (p = 0.44) and Medicare spending were similar (p = 0.65) among normal, overweight, and obese survivors. Total function limitations following severe sepsis did not differ by body mass index category (p = 0.64).

CONCLUSIONS: Obesity is associated with improved mortality among severe sepsis patients. Due to longer survival, obese sepsis survivors use more healthcare and result in higher Medicare spending in the year following hospitalization. Median daily healthcare utilization was similar across body mass index categories.

}, keywords = {Aged, Aged, 80 and over, Body Mass Index, Cohort Studies, Comorbidity, Critical Illness, Delivery of Health Care, Female, Health Expenditures, Hospitalization, Humans, Male, Medicare, Middle Aged, Obesity, Sepsis, Survival Rate, Survivors, United States}, issn = {1530-0293}, doi = {10.1097/CCM.0000000000000336}, author = {Hallie C Prescott and Virginia W Chang and James M. O{\textquoteright}Brien Jr and Kenneth M. Langa and Theodore J Iwashyna} } @article {7806, title = {Adults with cardiovascular disease who help others: a prospective study of health outcomes.}, journal = {J Behav Med}, volume = {36}, year = {2013}, note = {Copyright - Springer Science Business Media New York 2013 Last updated - 2013-04-30 DOI - 2922261571; 76454332; 69709; BVMD; 22481214; SPVLBVMD108653629414}, month = {2013 Apr}, pages = {199-211}, publisher = {36}, abstract = {

Little is known about the health impact of helping behaviors among individuals with high-risk chronic diseases such as cardiovascular disease (CVD). Using a nationally representative, longitudinal survey, we examined the subsequent health of adults with CVD (n~=~4,491) who spent time providing non-paid assistance to family and friends outside of their households compared with those who had provided no assistance. After both adjusting for baseline characteristics and using propensity score matching methods, spending up to 200~h over the prior 12~months helping others was associated with lower odds of experiencing a new CVD event or dying in the subsequent 2~years. Providing up to 100~h of assistance was associated with reporting fewer depressive symptoms. This threshold effect raises the question of whether assistance beyond a certain number of hours may impose a burden that mitigates health benefits from helping others. Health care providers could play an important role exploring ways that patients with CVD can provide beneficial levels of assistance to others in their own social networks or communities, thereby possibly also improving their own health.

}, keywords = {Activities of Daily Living, Aged, Cardiovascular Diseases, depression, Female, Health Status, Helping Behavior, Humans, Longitudinal Studies, Male, Middle Aged, Prospective Studies, Time Factors}, issn = {1573-3521}, doi = {10.1007/s10865-012-9414-4}, url = {http://search.proquest.com.proxy.lib.umich.edu/docview/1318045378?accountid=14667}, author = {Michele M Heisler and Choi, Hwajung and John D Piette and Ann Marie Rosland and Kenneth M. Langa and Stephanie Brown} } @article {7799, title = {Functional limitations in older adults who have cognitive impairment without dementia.}, journal = {J Geriatr Psychiatry Neurol}, volume = {26}, year = {2013}, note = {NLM Title Abbreviation: J Geriatr Psychiatry Neurol}, month = {2013 Jun}, pages = {78-85}, abstract = {

OBJECTIVE: To characterize the prevalence of functional limitations among older adults with cognitive impairment without dementia (CIND).

METHODS: Secondary data analysis was performed using the Aging, Demographics, and Memory Study data set. A total of 856 individuals aged >= 71 years were assigned to 3 diagnostic cognitive categories. A questionnaire was completed by a proxy informant regarding functional limitations for 744 of the 856 respondents.

RESULTS: Of the 744 patients, 263 (13.9\%) had dementia, 201 (21.3\%) had CIND, and 280 (64.8\%) had normal cognition. Informants reported >=1 instrumental activities of daily living (ADLs) limitation in 45\% of the patients with CIND compared to 13\% of the patients with normal cognition and 85\% of the patients with dementia (P < .001). The ADL impairments among individuals with CIND were primarily attributed to physical health problems (n = 41; 40\%).

CONCLUSIONS: Many individuals with CIND have impairment in a range of complex and basic daily activities, largely due to physical health problems.

}, keywords = {Activities of Daily Living, Age Factors, Aged, Aged, 80 and over, Cognitive Dysfunction, Dementia, Female, Humans, Male, Neuropsychological tests, Severity of Illness Index, Surveys and Questionnaires}, issn = {0891-9887}, doi = {10.1177/0891988713481264}, author = {Tanya R Gure and Kenneth M. Langa and Gwenith G Fisher and John D Piette and Brenda L Plassman} } @article {7911, title = {Trends in depressive symptom burden among older adults in the United States from 1998 to 2008.}, journal = {J Gen Intern Med}, volume = {28}, year = {2013}, month = {2013 Dec}, pages = {1611-9}, publisher = {28}, abstract = {

CONTEXT: Diagnosis and treatment of depression has increased over the past decade in the United States. Whether self-reported depressive symptoms among older adults have concomitantly declined is unknown.

OBJECTIVE: To examine trends in depressive symptoms among older adults in the US between 1998 and 2008.

DESIGN: Serial cross-sectional analysis of six biennial assessments.

SETTING: Health and Retirement Study (HRS), a nationally-representative survey. PATIENTS OR OTHER PARTICIPANTS Adults aged 55 and older (N = 16,184 in 1998).

MAIN OUTCOME MEASURE: The eight-item Center for Epidemiologic Studies Depression scale (CES-D8) assessed three levels of depressive symptoms (none = 0, elevated = 4+, severe = 6+), adjusting for demographic and clinical characteristics.

RESULTS: Having no depressive symptoms increased over the 10-year period from 40.9~\% to 47.4~\% (prevalence ratio [PR]: 1.16, 95 \% CI: 1.13-1.19), with significant increases in those aged >= 60 relative to those aged 55-59. There was a 7~\% prevalence reduction of elevated symptoms from 15.5~\% to 14.2~\% (PR: 0.93, 95 \% CI: 0.88-0.98), which was most pronounced among those aged 80-84 in whom the prevalence of elevated symptoms declined from 14.3~\% to 9.6~\%. Prevalence of having severe depressive symptoms increased from 5.8~\% to 6.8~\% (PR: 1.17, 95 \% CI: 1.06-1.28); however, this increase was limited to those aged 55-59, with the probability of severe symptoms increasing from 8.7~\% to 11.8~\%. No significant changes in severe symptoms were observed for those aged >= 60.

CONCLUSIONS: Overall late-life depressive symptom burden declined significantly from 1998 to 2008. This decrease appeared to be driven primarily by greater reductions in depressive symptoms in the oldest-old, and by an increase in those with no depressive symptoms. These changes in symptom burden were robust to physical, functional, demographic, and economic factors. Future research should examine whether this decrease in depressive symptoms is associated with improved treatment outcomes, and if there have been changes in the treatment received for the various age cohorts.

}, keywords = {Age Factors, Aged, Aged, 80 and over, Cohort Studies, Cost of Illness, Cross-Sectional Studies, depression, Female, Humans, Male, Middle Aged, United States}, issn = {1525-1497}, doi = {10.1007/s11606-013-2533-y}, author = {Zivin, Kara and Paul A Pirraglia and Ryan J McCammon and Kenneth M. Langa and Sandeep Vijan} } @article {7683, title = {Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study.}, journal = {Hepatology}, volume = {55}, year = {2012}, month = {2012 Jan}, pages = {184-91}, publisher = {55}, abstract = {

UNLABELLED: Prevalence of cirrhosis among older adults is expected to increase; therefore, we studied the health status, functional disability, and need for supportive care in a large national sample of individuals with cirrhosis. A prospective cohort of individuals with cirrhosis was identified within the longitudinal, nationally representative Health and Retirement Study. Cirrhosis cases were identified in linked Medicare data via ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes and compared to an age-matched cohort without cirrhosis. Two primary outcome domains were assessed: (1) patients{\textquoteright} health status (perceived health status, comorbidities, health care utilization, and functional disability as determined by activities of daily living and instrumental activities of daily living), and (2) informal caregiving (hours of caregiving provided by a primary informal caregiver and associated cost). Adjusted negative binomial regression was used to assess the association between cirrhosis and functional disability. A total of 317 individuals with cirrhosis and 951 age-matched comparators were identified. Relative to the comparison group, individuals with cirrhosis had worse self-reported health status, more comorbidities, and used significantly more health care services (hospitalizations, nursing home stays, physician visits; P < 0.001 for all bivariable comparisons). They also had greater functional disability (P < 0.001 for activities of daily living and instrumental activities of daily living), despite adjustment for covariates such as comorbidities and health care utilization. Individuals with cirrhosis received more than twice the number of informal caregiving hours per week (P < 0.001), at an annual cost of US $4700 per person.

CONCLUSION: Older Americans with cirrhosis have high rates of disability, health care utilization, and need for informal caregiving. Improved care coordination and caregiver support is necessary to optimize management of this frail population.

}, keywords = {Aged, Black People, Caregivers, Comorbidity, Cost of Illness, Databases, Factual, Disability Evaluation, Female, Health Care Costs, Health Status, Hispanic or Latino, Humans, Incidence, Liver Cirrhosis, Male, Medicaid, Medicare, Prevalence, Prospective Studies, Retirement, United States, White People}, issn = {1527-3350}, doi = {10.1002/hep.24616}, author = {M. O. Rakoski and Ryan J McCammon and John D Piette and Theodore J Iwashyna and J. A. Marrero and Lok, Anna S and Kenneth M. Langa and Volk, Michael L} } @article {7761, title = {Prevalence of cognitive impairment in older adults with heart failure.}, journal = {J Am Geriatr Soc}, volume = {60}, year = {2012}, month = {2012 Sep}, pages = {1724-9}, publisher = {60}, abstract = {

OBJECTIVES: To determine the prevalence of cognitive impairment in older adults with heart failure (HF).

DESIGN: Cross-sectional analysis of the 2004 wave of the nationally representative Health and Retirement Study linked to 2002 to 2004 Medicare administrative claims.

SETTING: United States, community.

PARTICIPANTS: Six thousand one hundred eighty-nine individuals aged 67 and older.

MEASUREMENTS: An algorithm was developed using a combination of self- and proxy report of a heart problem and the presence of one or more Medicare claims in administrative files using standard HF diagnostic codes. On the basis of the algorithm, three categories were created to characterize the likelihood of a HF diagnosis: high or moderate probability of HF, low probability of HF, and no HF. Cognitive function was assessed using a screening measure of cognitive function or according to proxy rating. Age-adjusted prevalence estimates of cognitive impairment were calculated for the three groups.

RESULTS: The prevalence of cognitive impairment consistent with dementia in older adults with HF was 15\%, and the prevalence of mild cognitive impairment was 24\%. The odds of dementia in those with HF were significantly higher, even after adjustment for age, education level, net worth, and prior stroke (odds ratio = 1.52, 95\% confidence interval = 1.14-2.02).

CONCLUSION: Cognitive impairment is common in older adults with HF and is independently associated with risk of dementia. A cognitive assessment should be routinely incorporated into HF-focused models of care.

}, keywords = {Aged, Aged, 80 and over, Algorithms, Chi-Square Distribution, Cognition Disorders, Cross-Sectional Studies, Demography, Female, Heart Failure, Humans, Logistic Models, Male, Medicare, Prevalence, United States}, issn = {1532-5415}, doi = {10.1111/j.1532-5415.2012.04097.x}, author = {Tanya R Gure and Caroline S Blaum and Bruno J Giordani and Todd M Koelling and Andrzej T Galecki and Susan J Pressler and Scott L Hummel and Kenneth M. Langa} } @article {7570, title = {Caring for individuals with dementia and cognitive impairment, not dementia: findings from the aging, demographics, and memory study.}, journal = {J Am Geriatr Soc}, volume = {59}, year = {2011}, month = {2011 Mar}, pages = {488-94}, publisher = {59}, abstract = {

OBJECTIVES: To compare the characteristics and outcomes of caregivers of adults with dementia with those of caregivers of adults with cognitive impairment, not dementia (CIND).

DESIGN: Cross-sectional.

SETTING: In-home assessment for cognitive impairment and self-administered caregiving questionnaire.

PARTICIPANTS: One hundred sixty-nine primary family caregivers of participants in the Aging, Demographics, and Memory Study (ADAMS). ADAMS participants were aged 71 and older drawn from the nationally representative Health and Retirement Study.

MEASUREMENTS: Neuropsychological testing, neurological examination, clinical assessment, and medical history were used to assign a diagnosis of normal cognition, CIND, or dementia. Caregiving measures included caregiving time, functional limitations, depressive symptoms, physical and emotional strain, caregiving rewards, caregiver health, and demographic characteristics.

RESULTS: Dementia caregivers spent approximately 9 hours per day providing care, compared with 4 hours per day for CIND caregivers (P=.001). Forty-four percent of dementia caregivers exhibited depressive symptoms, compared with 26.5\% of CIND caregivers (P=.03). Physical and emotional strains were similar in both groups of caregivers. Regardless of the strains, nearly all caregivers reported some benefits from providing care. Behavioral problems (P=.01) and difficulty with instrumental activities of daily living (P=.01) in persons with CIND partially explained emotional strain experienced by CIND caregivers. For those with dementia, behavioral problems predicted caregiver emotional strain (P<.001) and depressive symptoms (P=.01).

CONCLUSION: Although support services are available to dementia caregivers, CIND caregivers also expend considerable time and experience strains. The real caregiver burden of cognitive impairment in the U.S. population may therefore be greatly underestimated if people who have reached the diagnostic threshold for dementia are focused on exclusively.

}, keywords = {Activities of Daily Living, Aged, Analysis of Variance, Caregivers, Cognition Disorders, Cross-Sectional Studies, Dementia, Female, Humans, Linear Models, Male, Neuropsychological tests, Time Factors, United States}, issn = {1532-5415}, doi = {10.1111/j.1532-5415.2010.03304.x}, url = {http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2010.03304.x/full}, author = {Gwenith G Fisher and Melissa M Franks and Brenda L Plassman and Stephanie Brown and Guy G Potter and David J Llewellyn and Mary A M Rogers and Kenneth M. Langa} } @article {7586, title = {Incidence of dementia and cognitive impairment, not dementia in the United States.}, journal = {Ann Neurol}, volume = {70}, year = {2011}, month = {2011 Sep}, pages = {418-26}, abstract = {

OBJECTIVE: Estimates of incident dementia, and cognitive impairment, not dementia (CIND) (or the related mild cognitive impairment) are important for public health and clinical care policy. In this paper, we report US national incidence rates for dementia and CIND.

METHODS: Participants in the Aging, Demographic, and Memory Study (ADAMS) were evaluated for cognitive impairment using a comprehensive in-home assessment. A total of 456 individuals aged 72 years and older, who were not demented at baseline, were followed longitudinally from August 2001 to December 2009. An expert consensus panel assigned a diagnosis of normal cognition, CIND, or dementia and its subtypes. Using a population-weighted sample, we estimated the incidence of dementia, Alzheimer disease (AD), vascular dementia (VaD), and CIND by age. We also estimated the incidence of progression from CIND to dementia.

RESULTS: The incidence of dementia was 33.3 (standard error [SE], 4.2) per 1,000 person-years and 22.9 (SE, 2.9) per 1,000 person-years for AD. The incidence of CIND was 60.4 (SE, 7.2) cases per 1,000 person-years. An estimated 120.3 (SE, 16.9) individuals per 1,000 person-years progressed from CIND to dementia. Over a 5.9-year period, about 3.4 million individuals aged 72 and older in the United States developed incident dementia, of whom approximately 2.3 million developed AD, and about 637,000 developed VaD. Over this same period, almost 4.8 million individuals developed incident CIND.

INTERPRETATION: The incidence of CIND is greater than the incidence of dementia, and those with CIND are at high risk of progressing to dementia, making CIND a potentially valuable target for treatments aimed at slowing cognitive decline.

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Cognition Disorders, Cohort Studies, Dementia, Diagnostic and Statistical Manual of Mental Disorders, disease progression, Female, Humans, Logistic Models, Longitudinal Studies, Male, Models, Statistical, United States}, issn = {1531-8249}, doi = {10.1002/ana.22362}, author = {Brenda L Plassman and Kenneth M. Langa and Ryan J McCammon and Gwenith G Fisher and Guy G Potter and James R Burke and David C Steffens and Norman L Foster and Bruno J Giordani and Frederick W Unverzagt and Kathleen A Welsh-Bohmer and Steven G Heeringa and David R Weir and Robert B Wallace} } @article {7564, title = {National estimates of the prevalence of Alzheimer{\textquoteright}s disease in the United States.}, journal = {Alzheimers Dement}, volume = {7}, year = {2011}, month = {2011 Jan}, pages = {61-73}, publisher = {7}, abstract = {

Several methods of estimating prevalence of dementia are presented in this article. For both Brookmeyer and the Chicago Health and Aging project (CHAP), the estimates of prevalence are derived statistically, forward calculating from incidence and survival figures. The choice of incidence rates on which to build the estimates may be critical. Brookmeyer used incidence rates from several published studies, whereas the CHAP investigators applied the incidence rates observed in their own cohort. The Aging, Demographics, and Memory Study (ADAMS) and the East Boston Senior Health Project (EBSHP) were sample surveys designed to ascertain the prevalence of Alzheimer{\textquoteright}s disease and dementia. ADAMS obtained direct estimates by relying on probability sampling nationwide. EBSHP relied on projection of localized prevalence estimates to the national population. The sampling techniques of ADAMS and EBSHP were rather similar, whereas their disease definitions were not. By contrast, EBSPH and CHAP have similar disease definitions internally, but use different calculation techniques, and yet arrive at similar prevalence estimates, which are considerably greater than those obtained by either Brookmeyer or ADAMS. Choice of disease definition may play the larger role in explaining differences in observed prevalence between these studies.

}, keywords = {Age Factors, Alzheimer disease, Community Health Planning, Data collection, Humans, Incidence, Models, Statistical, Prevalence, Sampling Studies, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2010.11.007}, author = {Brookmeyer, Ron and Denis A Evans and Liesi Hebert and Kenneth M. Langa and Steven G Heeringa and Brenda L Plassman and Walter Kukull} } @article {7571, title = {Neuropsychiatric symptoms and the risk of institutionalization and death: the aging, demographics, and memory study.}, journal = {J Am Geriatr Soc}, volume = {59}, year = {2011}, month = {2011 Mar}, pages = {473-81}, publisher = {59}, abstract = {

OBJECTIVES: To examine the association between neuropsychiatric symptoms and risk of institutionalization and death.

DESIGN: Analysis of longitudinal data.

SETTING: The Aging, Demographics, and Memory Study (ADAMS).

PARTICIPANTS: Five hundred thirty-seven adults aged 71 and older with cognitive impairment drawn from the Health and Retirement Study (HRS).

MEASUREMENTS: Neuropsychiatric symptoms (delusions, hallucinations, agitation, depression, apathy, elation, anxiety, disinhibition, irritation, and aberrant motor behaviors) and caregiver distress were identified using the Neuropsychiatric Inventory. A consensus panel in the ADAMS assigned cognitive category. Date of nursing home placement and information on death, functional limitations, medical comorbidity, and sociodemographic characteristics were obtained from the HRS and ADAMS.

RESULTS: Overall, the presence of one or more neuropsychiatric symptoms was not associated with a significantly higher risk for institutionalization or death during the 5-year study period, although when assessing each symptom individually, depression, delusions, and agitation were each associated with a significantly higher risk of institutionalization (hazard rate (HR)=3.06, 95\% confidence interval (CI)=1.09-8.59 for depression; HR=5.74, 95\% CI=1.94-16.96 for clinically significant delusions; HR=4.70, 95\% CI=1.07-20.70 for clinically significant agitation). Caregiver distress mediated the association between delusions and agitation and institutionalization. Depression and hallucinations were associated with significantly higher mortality (HR=1.56, 95\% CI=1.08-2.26 for depression; HR=2.59, 95\% CI=1.09-6.16 for clinically significant hallucinations).

CONCLUSION: Some, but not all, neuropsychiatric symptoms are associated with a higher risk of institutionalization and death in people with cognitive impairment, and caregiver distress also influences institutionalization. Interventions that better target and treat depression, delusions, agitation, and hallucinations, as well as caregiver distress, may help delay or prevent these negative clinical outcomes.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Behavioral Symptoms, Caregivers, Cognition Disorders, Female, Humans, Institutionalization, Male, Neuropsychological tests, Proportional Hazards Models}, issn = {1532-5415}, doi = {10.1111/j.1532-5415.2011.03314.x}, author = {Okura, Toru and Brenda L Plassman and David C Steffens and David J Llewellyn and Guy G Potter and Kenneth M. Langa} } @article {7563, title = {Operationalizing diagnostic criteria for Alzheimer{\textquoteright}s disease and other age-related cognitive impairment-Part 2.}, journal = {Alzheimers Dement}, volume = {7}, year = {2011}, month = {2011 Jan}, pages = {35-52}, publisher = {7}, abstract = {

This article focuses on the effects of operational differences in case ascertainment on estimates of prevalence and incidence of cognitive impairment and/or dementia of the Alzheimer type. Experience and insights are discussed by investigators from the Framingham Heart Study, the East Boston Senior Health Project, the Chicago Health and Aging Project, the Mayo Clinic Study of Aging, the Baltimore Longitudinal Study of Aging, and the Aging, Demographics, and Memory Study. There is a general consensus that the single most important factor determining prevalence estimates of Alzheimer{\textquoteright}s disease (AD) is the severity of cognitive impairment used as a threshold to define cases. Studies that require a level of cognitive impairment in which persons are unable to provide self-care will have much lower estimates than the studies aimed at identifying persons in the earliest stages of AD. There are limited autopsy data from the aforementioned epidemiological studies to address accuracy in the diagnosis of etiological subtype, namely the specification of AD alone or in combination with other types of pathology. However, other community-based cohort studies show that many persons with mild cognitive impairment and also some persons without dementia or mild cognitive impairment meet pathological criteria for AD, thereby suggesting that the number of persons who would benefit from an effective secondary prevention intervention is probably higher than the published prevalence estimates. Improved accuracy in the clinical diagnosis of AD is anticipated with the addition of molecular and structural biomarkers in the next generation of epidemiological studies.

}, keywords = {Age Factors, Aging, Alzheimer disease, Cognition Disorders, Community Health Planning, Humans, Incidence, Longitudinal Studies, Neuropsychological tests, Prevalence, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2010.12.002}, author = {Seshadri, Sudha and Alexa S. Beiser and Au, Rhoda and Philip A Wolf and Robert S Wilson and Ronald C Petersen and David S Knopman and Walter A Rocca and Claudia H Kawas and Maria M Corrada and Brenda L Plassman and Kenneth M. Langa and Helena C Chui} } @article {7566, title = {Reducing case ascertainment costs in U.S. population studies of Alzheimer{\textquoteright}s disease, dementia, and cognitive impairment-Part 1.}, journal = {Alzheimers Dement}, volume = {7}, year = {2011}, month = {2011 Jan}, pages = {94-109}, publisher = {7}, abstract = {

Establishing methods for ascertainment of dementia and cognitive impairment that are accurate and also cost-effective is a challenging enterprise. Large population-based studies often using administrative data sets offer relatively inexpensive and reliable estimates of severe conditions including moderate to advanced dementia that are useful for public health planning, but they can miss less severe cognitive impairment which may be the most effective point for intervention. Clinical and epidemiological cohorts, intensively assessed, provide more sensitive detection of less severe cognitive impairment but are often costly. In this article, several approaches to ascertainment are evaluated for validity, reliability, and cost. In particular, the methods of ascertainment from the Health and Retirement Study are described briefly, along with those of the Aging, Demographics, and Memory Study (ADAMS). ADAMS, a resource-intense sub-study of the Health and Retirement Study, was designed to provide diagnostic accuracy among persons with more advanced dementia. A proposal to streamline future ADAMS assessments is offered. Also considered are algorithmic and Web-based approaches to diagnosis that can reduce the expense of clinical expertise and, in some contexts, can reduce the extent of data collection. These approaches are intended for intensively assessed epidemiological cohorts where goal is valid and reliable case detection with efficient and cost-effective tools.

}, keywords = {Aging, Algorithms, Alzheimer disease, Cognition Disorders, Community Health Planning, Cost-Benefit Analysis, Dementia, Health Surveys, Humans, Internet, Reproducibility of Results, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2010.11.004}, url = {http://mgetit.lib.umich.edu/sfx_local?ctx_enc=info 3Aofi 2Fenc 3AUTF-8;ctx_id=10_1;ctx_tim=2011-03-28T16 3A26 3A0EDT;ctx_ver=Z39.88-2004;rfr_id=info 3Asid 2Fsfxit.com 3Acitation;rft.genre=article;rft_id=info 3Apmid 2F21255747;rft_val_fmt=info 3Aofi 2Ffmt }, author = {David R Weir and Robert B Wallace and Kenneth M. Langa and Brenda L Plassman and Robert S Wilson and David A Bennett and Duara, Ranjan and Loewenstein, David and Ganguli, Mary and Sano, Mary} } @article {7565, title = {Sources of variability in estimates of the prevalence of Alzheimer{\textquoteright}s disease in the United States.}, journal = {Alzheimers Dement}, volume = {7}, year = {2011}, month = {2011 Jan}, pages = {74-9}, publisher = {7}, abstract = {

BACKGROUND: The prevalence of Alzheimer{\textquoteright}s disease (AD) in the United States was estimated at 2.3 million in 2002 by the Aging, Demographics, and Memory Study (ADAMS), which is almost 50\% less than the estimate of 4.5 million in 2000 derived from the Chicago Health and Aging Project.

METHODS: We considered how differences in diagnostic criteria may have contributed to these differences in AD prevalence.

RESULTS: We identified several important differences in diagnostic criteria that may have contributed to the differing estimates of AD prevalence. Two factors were especially noteworthy. First, the Diagnostic and Statistical Manual of Mental Disorders III-R and IV criteria of functional limitation documented by an informant used in ADAMS effectively concentrated the diagnosis of dementia toward a relatively higher level of cognitive impairment. ADAMS separately identified a category of cognitive impairment not dementia and within that group there were a substantial number of cases with "prodromal" AD (a maximum of 1.95 million with upweighting). Second, a substantial proportion of dementia in ADAMS was attributed to either vascular disease (representing a maximum of 0.59 million with upweighting) or undetermined etiology (a maximum of 0.34 million), whereas most dementia, including mixed dementia, was attributed to AD in the Chicago Health and Aging Project.

CONCLUSION: The diagnosis of AD in population studies is a complex process. When a diagnosis of AD excludes persons meeting criteria for vascular dementia, when not all persons with dementia are assigned an etiology, and when a diagnosis of dementia requires an informant report of functional limitations, the prevalence is substantially lower and the diagnosed cases most likely have a relatively higher level of impairment.

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Community Health Planning, Comorbidity, Dementia, Diagnosis, Differential, Female, Humans, Incidence, Male, Prevalence, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2010.11.006}, author = {Robert S Wilson and David R Weir and Sue E Leurgans and Denis A Evans and Liesi Hebert and Kenneth M. Langa and Brenda L Plassman and Brent J. Small and David A Bennett} } @article {7567, title = {Trends in the incidence and prevalence of Alzheimer{\textquoteright}s disease, dementia, and cognitive impairment in the United States.}, journal = {Alzheimers Dement}, volume = {7}, year = {2011}, month = {2011 Jan}, pages = {80-93}, publisher = {7}, 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.

}, keywords = {Age Factors, Alzheimer disease, Cognition Disorders, Cohort Studies, Community Health Planning, Dementia, Humans, Incidence, Prevalence, Residence Characteristics, Retrospective Studies, Time Factors, United States}, issn = {1552-5279}, doi = {10.1016/j.jalz.2010.11.002}, author = {Walter A Rocca and Ronald C Petersen and David S Knopman and Liesi Hebert and Denis A Evans and Kathleen S Hall and Gao, Sujuan and Frederick W Unverzagt and Kenneth M. Langa and Eric B Larson and Lon R White} } @article {7530, title = {The case for involving adult children outside of the household in the self-management support of older adults with chronic illnesses.}, journal = {Chronic Illn}, volume = {6}, year = {2010}, month = {2010 Mar}, pages = {34-45}, publisher = {6}, abstract = {

OBJECTIVES: This study sought to (1) identify barriers to spousal support for chronic illness self-care among community-dwelling older adults; and (2) describe the potential availability of self-care support from adult children living outside of the household.

METHODS: Nationally representative US sample of chronically ill adults aged 51+ were interviewed as part of the Health and Retirement Study (N = 14,862). Both participants and their spouses (when available) reported information about their health and functioning. Participants also reported information about their contact with adult children and the quality of those relationships.

RESULTS: More than one-third (38\%) of chronically ill older adults in the US are unmarried; and when spouses are available, the majority of them have multiple chronic diseases and functional limitations. However, the vast majority of chronically ill older adults (93\%, representing roughly 60 million Americans) have adult children, with half having children living over 10 miles away. Most respondents with children (78\%) reported at least weekly telephone contact and that these relationships were positive. Roughly 19 million older chronically ill Americans have adult children living at a distance but none nearby; these children are in frequent telephone contact and respondents (including those with multiple chronic diseases) report that the relationships are positive.

DISCUSSION: As the gap between available health services for disease management and the need among community-dwelling patients continues to grow, adult children-including those living at a distance-represent an important resource for improving self-care support for people with chronic diseases.

}, keywords = {Adult, Chronic disease, Family Relations, Female, Humans, Male, Middle Aged, Self Care, Social Support}, issn = {1745-9206}, doi = {10.1177/1742395309347804}, author = {John D Piette and Ann Marie Rosland and Maria J Silveira and Mohammed U Kabeto and Kenneth M. Langa} } @article {7464, title = {Differences in functional impairment across subtypes of dementia.}, journal = {J Gerontol A Biol Sci Med Sci}, volume = {65}, year = {2010}, month = {2010 Apr}, pages = {434-41}, publisher = {65A}, abstract = {

BACKGROUND: Dementia is a cause of disability in later life. Despite the importance of functional status to the diagnosis of dementia, limited information exists on differences in functional limitations by dementia subtype. We conducted a cross-sectional analysis using the Aging, Demographics, and Memory Study (ADAMS) to determine the extent of functional impairment among older adults with dementia due to different etiologies.

METHODS: The ADAMS sample consisted of 856 individuals aged 71 years and older originally surveyed as part of the Health and Retirement Study. Based on a comprehensive in-person cognitive evaluation, respondents were assigned to diagnostic categories of normal cognition, cognitive impairment not demented, and demented. Dementia subtypes were grouped into three categories: vascular dementia (VaD), Alzheimer{\textquoteright}s dementia (AD), and dementia due to other etiologies. For 744 of the 856 respondents, a proxy informant completed a questionnaire asking whether the respondent had difficulty completing instrumental activities of daily living and activities of daily living (ADLs).

RESULTS: Of 744 ADAMS participants, 263 had dementia: 199 (70.5\%) with AD, 42 (16.9\%) with VaD, and 22 (12.6\%) were demented due to other etiologies. After adjustment for demographics, chronic illnesses, and dementia severity, participants with VaD (odds ratio [OR] 5.74; 95\% confidence interval [CI] 2.60-12.69) and other etiologies of dementia (OR 21.23; 95\% CI 7.25-62.16) were more likely to have greater than or equal to four ADL limitations compared with those with AD.

CONCLUSIONS: VaD is associated with significantly more ADL limitations than AD. These physical limitations should be considered when designing adult day care programs, which adequately accommodate the needs of non-AD patients.

}, keywords = {Activities of Daily Living, Aged, Alzheimer disease, Dementia, Dementia, Vascular, Humans}, issn = {1758-535X}, doi = {10.1093/gerona/glp197}, author = {Tanya R Gure and Mohammed U Kabeto and Brenda L Plassman and John D Piette and Kenneth M. Langa} } @article {7476, title = {Factors influencing cost-related nonadherence to medication in older adults: a conceptually based approach.}, journal = {Value Health}, volume = {13}, year = {2010}, month = {2010 Jun-Jul}, pages = {338-45}, publisher = {13}, abstract = {

OBJECTIVE: Although multiple noncost factors likely influence a patient{\textquoteright}s propensity to forego treatment in the face of cost pressures, little is known about how patients{\textquoteright} sociodemographic characteristics, physical and behavioral health comorbidities, and prescription regimens influence cost-related nonadherence (CRN) to medications. We sought to determine both financial and nonfinancial factors associated with CRN in a nationally representative sample of older adults.

METHODS: We used a conceptual model developed by Piette and colleagues that describes financial and nonfinancial factors that could increase someone{\textquoteright}s risk of CRN, including income, comorbidities, and medication regimen complexity. We used data from the 2004 wave of the Health and Retirement Study and the 2005 HRS Prescription Drug Study to examine the influence of factors within each of these domains on measures of CRN (including not filling, stopping, or skipping doses) in a nationally representative sample of Americans age 65+ in 2005.

RESULTS: Of the 3071 respondents who met study criteria, 20\% reported some form of CRN in 2005. As in prior studies, indicators of financial stress such as higher out-of-pocket payments for medications and lower net worth were significantly associated with CRN in multivariable analyses. Controlling for these economic pressures, relatively younger respondents (ages 65-74) and depressive symptoms were consistent independent risk factors for CRN.

CONCLUSIONS: Noncost factors influenced patients{\textquoteright} propensity to forego treatment even in the context of cost concerns. Future research encompassing clinician and health system factors should identify additional determinants of CRN beyond patients{\textquoteright} cost pressures.

}, keywords = {Aged, Aged, 80 and over, Chronic disease, Female, Financing, Personal, Health Status, Humans, Logistic Models, Male, Medication Adherence, Models, Econometric, Multivariate Analysis, Prescription Fees, Risk Factors, Socioeconomic factors, United States}, issn = {1524-4733}, doi = {10.1111/j.1524-4733.2009.00679.x}, author = {Zivin, Kara and Scott M Ratliff and Michele M Heisler and Kenneth M. Langa and John D Piette} } @article {7450, title = {Hospitalizations and deaths among adults with cardiovascular disease who underuse medications because of cost: a longitudinal analysis.}, journal = {Med Care}, volume = {48}, year = {2010}, note = {Using Smart Source Parsing Feb Comment In: Med Care. 2010 Feb;48(2):85-6 20057326 Index Medicus}, month = {2010 Feb}, pages = {87-94}, publisher = {48}, abstract = {

CONTEXT: It is well-documented that the financial burden of out-of-pocket expenditures for prescription drugs often leads people with medication-sensitive chronic illnesses to restrict their use of these medications. Less is known about the extent to which such cost-related medication underuse is associated with increases in subsequent hospitalizations and deaths.

OBJECTIVE: We compared the risk of hospitalizations among 5401 and of death among 6135 middle-aged and elderly adults with one or more cardiovascular diseases (diabetes, coronary artery disease, heart failure, and history of stroke) according to whether participants did or did not report restricting prescription medications because of cost.

DESIGN AND SETTING: A retrospective biannual cohort study across 4 cross-sectional waves of the Health and Retirement Study, a nationally representative survey of adults older than age 50. Using multivariate logistic regression to adjust for baseline differences in sociodemographic and health characteristics, we assessed subsequent hospitalizations and deaths between 1998 and 2006 for respondents who reported that they had or had not taken less medicine than prescribed because of cost.

RESULTS: Respondents with cardiovascular disease who reported underusing medications due to cost were significantly more likely to be hospitalized in the next 2 years, even after adjusting for other patient characteristics (adjusted predicted probability of 47\% compared with 38\%, P < 0.001). The more survey waves respondents reported cost-related medication underuse during 1998 to 2004, the higher the probability of being hospitalized in 2006 (adjusted predicted probability of 54\% among respondents reporting cost-related medication underuse in all 4 survey waves compared with 42\% among respondents reporting no underuse, P < 0.001). There was no independent association of cost-related medication underuse with death.

CONCLUSIONS: In this nationally representative cohort, middle-aged and elderly adults with cardiovascular disease who reported cutting back on medication use because of cost were more likely to report being hospitalized over a subsequent 2-year period after they had reported medication underuse. The more extensively respondents reported cost-related underuse over time, the higher their adjusted predicted probability of subsequent hospitalization.

}, keywords = {Aged, Aged, 80 and over, Cardiovascular Diseases, Female, Financing, Personal, Health Care Costs, Health Services Accessibility, Health Status Disparities, Hospitalization, Humans, Logistic Models, Longitudinal Studies, Male, Medication Adherence, Middle Aged, Multivariate Analysis, Risk Factors, United States}, issn = {1537-1948}, doi = {10.1097/MLR.0b013e3181c12e53}, author = {Michele M Heisler and Choi, Hwajung and Allison B Rosen and Sandeep Vijan and Mohammed U Kabeto and Kenneth M. Langa and John D Piette} } @article {7441, title = {Prevalence of neuropsychiatric symptoms and their association with functional limitations in older adults in the United States: the aging, demographics, and memory study.}, journal = {J Am Geriatr Soc}, volume = {58}, year = {2010}, month = {2010 Feb}, pages = {330-7}, publisher = {58}, abstract = {

OBJECTIVES: To estimate the prevalence of neuropsychiatric symptoms and examine their association with functional limitations.

DESIGN: Cross-sectional analysis.

SETTING: The Aging, Demographics, and Memory Study (ADAMS).

PARTICIPANTS: A sample of adults aged 71 and older (N=856) drawn from Health and Retirement Study (HRS), a nationally representative cohort of U.S. adults aged 51 and older.

MEASUREMENTS: The presence of neuropsychiatric symptoms (delusions, hallucinations, agitation, depression, apathy, elation, anxiety, disinhibition, irritation, and aberrant motor behaviors) was identified using the Neuropsychiatric Inventory. A consensus panel in the ADAMS assigned a cognitive category (normal cognition; cognitive impairment, no dementia (CIND); mild, moderate, or severe dementia). Functional limitations, chronic medical conditions, and sociodemographic information were obtained from the HRS and ADAMS.

RESULTS: Forty-three percent of individuals with CIND and 58\% of those with dementia exhibited at least one neuropsychiatric symptom. Depression was the most common individual symptom in those with normal cognition (12\%), CIND (30\%), and mild dementia (25\%), whereas apathy (42\%) and agitation (41\%) were most common in those with severe dementia. Individuals with three or more symptoms and one or more clinically significant symptoms had significantly higher odds of having functional limitations. Those with clinically significant depression had higher odds of activity of daily living limitations, and those with clinically significant depression, anxiety, or aberrant motor behaviors had significantly higher odds of instrumental activity of daily living limitations.

CONCLUSION: Neuropsychiatric symptoms are highly prevalent in older adults with CIND and dementia. Of those with cognitive impairment, a greater number of total neuropsychiatric symptoms and some specific individual symptoms are strongly associated with functional limitations.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Behavioral Symptoms, Cognition Disorders, Cross-Sectional Studies, Dementia, Female, Humans, Male, Mental Disorders, Prevalence, United States}, issn = {1532-5415}, doi = {10.1111/j.1532-5415.2009.02680.x}, author = {Okura, Toru and Brenda L Plassman and David C Steffens and David J Llewellyn and Guy G Potter and Kenneth M. Langa} } @article {7524, title = {Vascular health, diabetes, APOE and dementia: the Aging, Demographics, and Memory Study.}, journal = {Alzheimers Res Ther}, volume = {2}, year = {2010}, month = {2010 Jun 24}, pages = {19}, publisher = {2}, abstract = {

INTRODUCTION: Evidence from clinical samples and geographically limited population studies suggests that vascular health, diabetes and apolipoprotein epsilon4 (APOE) are associated with dementia.

METHODS: A population-based sample of 856 individuals aged 71 years or older from all contiguous regions of the United States received an extensive in-home clinical and neuropsychological assessment in 2001-2003. The relation of hypertension, diabetes, heart disease, stroke, medication usage, and APOE epsilon4 to dementia was modelled using adjusted multivariable logistic regression.

RESULTS: Treated stroke (odds ratio [OR] 3.8, 95\% confidence interval [CI] 2.0, 7.2), untreated stroke (OR 3.5, 95\% CI 1.7, 7.3), and APOE epsilon4 (OR 2.8, 95\% CI 1.7, 4.5) all increased the odds of dementia. Treated hypertension was associated with lower odds of dementia (OR 0.5, 95\% CI 0.3, 1.0). Diabetes and heart disease were not significantly associated with dementia. A significant interaction was observed between APOE epsilon4 and stroke (P = 0.001).

CONCLUSIONS: Data from the first dementia study that is representative of the United States population suggest that stroke, the APOE epsilon4 allele and their interaction are strongly associated with dementia.

}, issn = {1758-9193}, doi = {10.1186/alzrt43}, url = {http://alzres.com/content/2/3/19}, author = {David J Llewellyn and Iain A Lang and Fiona E Matthews and Brenda L Plassman and Mary A M Rogers and Lewis B Morgenstern and Gwenith G Fisher and Mohammed U Kabeto and Kenneth M. Langa} } @article {7403, title = {The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited.}, journal = {J Alzheimers Dis}, volume = {17}, year = {2009}, month = {2009}, pages = {807-15}, publisher = {17}, abstract = {

Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We compared Medicare claims from 1993-2005 to clinical dementia assessments carried out in 2001-2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110\% increase in costs for those with dementia as compared to a 68\% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia.

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Cohort Studies, Dementia, Female, Health Care Costs, Humans, Insurance Claim Reporting, Male, Medicare, Prevalence, Sensitivity and Specificity, United States}, issn = {1875-8908}, doi = {10.3233/JAD-2009-1099}, author = {Donald H. Taylor Jr. and {\O}stbye, Truls and Kenneth M. Langa and David R Weir and Brenda L Plassman} } @article {5761, title = {Aging, Demographics and Memory Study (ADAMS): Sample Design, Weighting and Analysis for ADAMS}, year = {2009}, institution = {Institute for Social Research, University of Michigan}, address = {Ann Arbor, Michigan}, abstract = {This technical report describes the sample design, design-based weighting and analysis procedures for the Aging, Demographics and Memory Study (ADAMS), a national study that recruited Health and Retirement Study (HRS) panel members to undergo a psychometric evaluation and clinical assessment visit. Langa et al. (2005) describe the general design and methods for the ADAMS including relevant background on the HRS longitudinal sample. This document provides additional detail on the sample design for the ADAMS including a description of survey sample selection, sample attrition and nonresponse, population weights, design-based variance estimation and related topics of importance to analysts of the ADAMS data.}, keywords = {Health Conditions and Status, Methodology}, author = {Steven G Heeringa and Gwenith G Fisher and Michael D Hurd and Kenneth M. Langa and Mary Beth Ofstedal and Brenda L Plassman and Rogers, Willard and David R Weir} } @article {7303, title = {Caregiving behavior is associated with decreased mortality risk.}, journal = {Psychol Sci}, volume = {20}, year = {2009}, month = {2009 Apr}, pages = {488-94}, publisher = {20}, abstract = {

Traditional investigations of caregiving link it to increased caregiver morbidity and mortality, but do not disentangle the effects of providing care from those of being continuously exposed to an ailing loved one with serious health problems. We explored this possible confound in a national, longitudinal survey of elderly married individuals (N= 3,376). Results showed that spending at least 14 hr per week providing care to a spouse predicted decreased mortality for the caregiver, independently of behavioral and cognitive limitations of the care recipient (spouse), and of other demographic and health variables. These findings suggest that it may be premature to conclude that health risks for caregivers are due to providing active help. Indeed, under some circumstances, caregivers may actually benefit from providing care.

}, keywords = {Altruism, Caregivers, Humans, Mortality}, issn = {1467-9280}, doi = {10.1111/j.1467-9280.2009.02323.x}, url = {http://pss.sagepub.com/content/20/4/4}, author = {Stephanie Brown and Dylan M Smith and Schulz, Richard and Mohammed U Kabeto and Peter A. Ubel and Poulin, Michael and Yi, Jaehee and Kim, Catherine and Kenneth M. Langa} } @article {7413, title = {Cognitive performance and informant reports in the diagnosis of cognitive impairment and dementia in African Americans and whites.}, journal = {Alzheimers Dement}, volume = {5}, year = {2009}, month = {2009 Nov}, pages = {445-53}, publisher = {5}, abstract = {

BACKGROUND: The diagnosis of cognitive impairment and dementia must reflect an increasingly diverse and aging United States population. This study compared direct testing and informant reports of cognition with clinical diagnoses of cognitive impairment and dementia between African Americans and whites.

METHODS: Participants in the Aging, Demographics, and Memory Study completed in-person dementia evaluations, and were assigned clinical diagnoses (by a consensus panel of dementia experts) of normal; cognitive impairment, not demented (CIND); and dementia. The Consortium to Establish a Registry for Alzheimer{\textquoteright}s Disease (CERAD) total score and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) were used to assess cognitive performance and reported cognitive decline.

RESULTS: A higher CERAD total score was associated with lower odds of CIND and dementia, at comparable ratios between African Americans and whites. Higher IQCODE scores were associated with increased odds of dementia in both African Americans and whites. Higher IQCODE scores were associated with increased odds of CIND among whites, but not among African Americans.

CONCLUSIONS: Cultural differences may influence informant reports of prevalent CIND and dementia. Our findings also highlight the need for more comparative research to establish the cultural validity of measures used to diagnose these conditions.

}, keywords = {Activities of Daily Living, Age of Onset, Aged, Aged, 80 and over, Black or African American, Caregivers, Cognition Disorders, Cohort Studies, Culture, Dementia, Disability Evaluation, Female, Geriatric Assessment, Health Surveys, Humans, Male, Neuropsychological tests, Observer Variation, Population Surveillance, Predictive Value of Tests, Prevalence, Psychiatric Status Rating Scales, Psychometrics, Registries, Sensitivity and Specificity, Surveys and Questionnaires, White People}, issn = {1552-5279}, doi = {10.1016/j.jalz.2009.04.1234}, author = {Guy G Potter and Brenda L Plassman and James R Burke and Mohammed U Kabeto and Kenneth M. Langa and David J Llewellyn and Mary A M Rogers and David C Steffens} } @article {7316, title = {Parental education and late-life dementia in the United States.}, journal = {J Geriatr Psychiatry Neurol}, volume = {22}, year = {2009}, month = {2009 Mar}, pages = {71-80}, publisher = {22}, abstract = {

We investigated the relation between parental education and dementia in the United States. Participants in the Aging, Demographics, and Memory Study were included, with information regarding parental education obtained from the Health and Retirement Study. The odds of dementia in elderly Americans whose mothers had less then 8 years of schooling were twice (95\% CI, 1.1-3.8) that of individuals with higher maternal education, when adjusted for paternal education. Of elderly Americans with less educated mothers, 45.4\% (95\% CI, 37.4-53.4\%) were diagnosed with dementia or ;;cognitive impairment, no dementia{\textquoteright}{\textquoteright} compared to 31.2\% (95\% CI, 25.0-37.4\%) of elderly Americans whose mothers had at least an 8th grade education. The population attributable risk of dementia due to low maternal education was 18.8\% (95\% CI, 9.4-28.2\%). The education of girls in a population may be protective of dementia in the next generation.

}, keywords = {Age Distribution, Aged, Aged, 80 and over, Apolipoproteins E, Biomarkers, Cognition Disorders, Dementia, Educational Status, Fathers, Female, Genetic Predisposition to Disease, Humans, Longitudinal Studies, Male, Mothers, Odds Ratio, Parents, Prevalence, Prospective Studies, Racial Groups, Risk Factors, Sex Distribution, United States}, issn = {0891-9887}, doi = {10.1177/0891988708328220}, author = {Mary A M Rogers and Brenda L Plassman and Mohammed U Kabeto and Gwenith G Fisher and John J McArdle and David J Llewellyn and Guy G Potter and Kenneth M. Langa} } @article {7349, title = {Prevalence of depression among older Americans: the Aging, Demographics and Memory Study.}, journal = {Int Psychogeriatr}, volume = {21}, year = {2009}, note = {PMID: 19519984}, month = {2009 Oct}, pages = {879-88}, publisher = {21}, abstract = {

BACKGROUND: Previous studies have attempted to provide estimates of depression prevalence in older adults. The Aging, Demographics and Memory Study (ADAMS) is a population-representative study that included a depression assessment, providing an opportunity to estimate the prevalence of depression in late life in the U.S.A.

METHODS: The ADAMS sample was drawn from the larger Health and Retirement Study. A total of 851 of 856 ADAMS participants aged 71 and older had available depression data. Depression was measured using the Composite International Diagnostic Interview - Short Form (CIDI-SF) and the informant depression section of the Neuropsychiatric Inventory (NPI). We estimated the national prevalence of depression, stratified by age, race, sex, and cognitive status. Logistic regression analyses were performed to examine the association of depression and previously reported risk factors for the condition.

RESULTS: When combining symptoms of major or minor depression with reported treatment for depression, we found an overall depression prevalence of 11.19\%. Prevalence was similar for men (10.19\%) and women (11.44\%). Whites and Hispanics had nearly three times the prevalence of depression found in African-Americans. Dementia diagnosis and pain severity were associated with increased depression prevalence, while black race was associated with lower rates of depression.

CONCLUSIONS: The finding of similar prevalence estimates for depression in men and women was not consistent with prior research that has shown a female predominance. Given the population-representativeness of our sample, similar depression rates between the sexes in ADAMS may result from racial, ethnic and socioeconomic diversity.

}, keywords = {Aged, Aged, 80 and over, Alzheimer disease, Black People, Cohort Studies, Comorbidity, Cross-Sectional Studies, Depressive Disorder, Female, Health Status, Hispanic or Latino, Humans, Male, Neuropsychological tests, Personality Assessment, Sex Factors, Socioeconomic factors, United States, White People}, issn = {1041-6102}, doi = {10.1017/S1041610209990044}, author = {David C Steffens and Gwenith G Fisher and Kenneth M. Langa and Guy G Potter and Brenda L Plassman} } @article {7201, title = {Prevalence of cognitive impairment without dementia in the United States.}, journal = {Ann Intern Med}, volume = {148}, year = {2008}, month = {2008 Mar 18}, pages = {427-34}, publisher = {148}, abstract = {

BACKGROUND: Cognitive impairment without dementia is associated with increased risk for disability, increased health care costs, and progression to dementia. There are no population-based prevalence estimates of this condition in the United States.

OBJECTIVE: To estimate the prevalence of cognitive impairment without dementia in the United States and determine longitudinal cognitive and mortality outcomes.

DESIGN: Longitudinal study from July 2001 to March 2005.

SETTING: In-home assessment for cognitive impairment.

PARTICIPANTS: Participants in ADAMS (Aging, Demographics, and Memory Study) who were age 71 years or older drawn from the nationally representative HRS (Health and Retirement Study). Of 1770 selected individuals, 856 completed initial assessment, and of 241 selected individuals, 180 completed 16- to 18-month follow-up assessment.

MEASUREMENTS: Assessments, including neuropsychological testing, neurologic examination, and clinical and medical history, were used to assign a diagnosis of normal cognition, cognitive impairment without dementia, or dementia. National prevalence rates were estimated by using a population-weighted sample.

RESULTS: In 2002, an estimated 5.4 million people (22.2\%) in the United States age 71 years or older had cognitive impairment without dementia. Prominent subtypes included prodromal Alzheimer disease (8.2\%) and cerebrovascular disease (5.7\%). Among participants who completed follow-up assessments, 11.7\% with cognitive impairment without dementia progressed to dementia annually, whereas those with subtypes of prodromal Alzheimer disease and stroke progressed at annual rates of 17\% to 20\%. The annual death rate was 8\% among those with cognitive impairment without dementia and almost 15\% among those with cognitive impairment due to medical conditions.

LIMITATIONS: Only 56\% of the nondeceased target sample completed the initial assessment. Population sampling weights were derived to adjust for at least some of the potential bias due to nonresponse and attrition.

CONCLUSION: Cognitive impairment without dementia is more prevalent in the United States than dementia, and its subtypes vary in prevalence and outcomes.

}, keywords = {Aged, Aged, 80 and over, Cognition Disorders, Dementia, disease progression, Humans, Longitudinal Studies, Prevalence, United States}, issn = {1539-3704}, doi = {10.7326/0003-4819-148-6-200803180-00005}, author = {Brenda L Plassman and Kenneth M. Langa and Gwenith G Fisher and Steven G Heeringa and David R Weir and Mary Beth Ofstedal and James R Burke and Michael D Hurd and Guy G Potter and Willard L Rodgers and David C Steffens and John J McArdle and Robert J. Willis and Robert B Wallace} } @article {7173, title = {Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients{\textquoteright} treatment priorities and self-management?}, journal = {J Gen Intern Med}, volume = {22}, year = {2007}, month = {2007 Dec}, pages = {1635-40}, publisher = {22}, abstract = {

BACKGROUND: The majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40\% have at least three.

OBJECTIVE: We sought to understand how the number, type, and severity of comorbidities influence diabetes patients{\textquoteright} self-management and treatment priorities.

DESIGN: Cross-sectional observation study.

PATIENTS: A total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.

MEASUREMENTS: We constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).

RESULTS: 40\% of respondents had at least 1 microvascular comorbidity, 79\% at least 1 macrovascular comorbidity, and 61\% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.

CONCLUSIONS: The type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients{\textquoteright} self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.

}, keywords = {Aged, Attitude to Health, Cohort Studies, Comorbidity, Cross-Sectional Studies, Diabetes Mellitus, Female, Health Priorities, Heart Failure, Humans, Male, Middle Aged, Self Care, Severity of Illness Index, United States}, issn = {1525-1497}, doi = {10.1007/s11606-007-0313-2}, author = {Eve A Kerr and Michele M Heisler and Sarah L. Krein and Mohammed U Kabeto and Kenneth M. Langa and David R Weir and John D Piette} } @article {7164, title = {Prevalence of dementia in the United States: the aging, demographics, and memory study.}, journal = {Neuroepidemiology}, volume = {29}, year = {2007}, month = {2007}, pages = {125-32}, publisher = {29}, abstract = {

AIM: To estimate the prevalence of Alzheimer{\textquoteright}s disease (AD) and other dementias in the USA using a nationally representative sample.

METHODS: The Aging, Demographics, and Memory Study sample was composed of 856 individuals aged 71 years and older from the nationally representative Health and Retirement Study (HRS) who were evaluated for dementia using a comprehensive in-home assessment. An expert consensus panel used this information to assign a diagnosis of normal cognition, cognitive impairment but not demented, or dementia (and dementia subtype). Using sampling weights derived from the HRS, we estimated the national prevalence of dementia, AD and vascular dementia by age and gender.

RESULTS: The prevalence of dementia among individuals aged 71 and older was 13.9\%, comprising about 3.4 million individuals in the USA in 2002. The corresponding values for AD were 9.7\% and 2.4 million individuals. Dementia prevalence increased with age, from 5.0\% of those aged 71-79 years to 37.4\% of those aged 90 and older.

CONCLUSIONS: Dementia prevalence estimates from this first nationally representative population-based study of dementia in the USA to include subjects from all regions of the country can provide essential information for effective planning for the impending healthcare needs of the large and increasing number of individuals at risk for dementia as our population ages.

}, keywords = {Age Distribution, Aged, Aged, 80 and over, Cohort Studies, Dementia, Female, Geriatric Assessment, Health Surveys, Humans, Logistic Models, Male, Prevalence, Sex Distribution, United States}, issn = {1423-0208}, doi = {10.1159/000109998}, author = {Brenda L Plassman and Kenneth M. Langa and Gwenith G Fisher and Steven G Heeringa and David R Weir and Mary Beth Ofstedal and James R Burke and Michael D Hurd and Guy G Potter and Willard L Rodgers and David C Steffens and Robert J. Willis and Robert B Wallace} } @article {7002, title = {The Aging, Demographics and Memory Study: Study Design and Methods}, journal = {Neuroepidemiology}, volume = {25}, year = {2005}, pages = {181-191}, publisher = {25}, abstract = {Objective: We describe the design and methods of the Aging, Demographics, and Memory Study (ADAMS), a new national study that will provide data on the antecedents, prevalence, outcomes, and costs of dementia and cognitive impairment, not demented (CIND) using a unique study design based on the nationally representative Health and Retirement Study (HRS). We also illustrate potential uses of the ADAMS data and provide information to interested researchers on obtaining ADAMS and HRS data. Methods: The ADAMS is the first population-based study of dementia in the United States to include subjects from all regions of the country, while at the same time using a single standardized diagnostic protocol in a community-based sample. A sample of 856 individuals aged 70 or older who were participants in the on-going HRS received an extensive in-home clinical and neuropsychological assessment to determine a diagnosis of normal, CIND, or dementia. Within the CIND and dementia categories, subcategories (e.g., Alzheimer disease, vascular dementia) were assigned to denote the etiology of cognitive impairment. Conclusion: Linking the ADAMS dementia clinical assessment data to the wealth of available longitudinal HRS data on health, health care utilization, informal care, and economic resources and behavior, will provide a unique opportunity to study the onset of CIND and dementia in a nationally-representative population-based sample, as well as the risk factors, prevalence, outcomes, and costs of CIND and dementia.}, keywords = {Health Conditions and Status, Healthcare}, author = {Kenneth M. Langa and Brenda L Plassman and Robert B Wallace and A. Regula Herzog and Steven G Heeringa and Mary Beth Ofstedal and James F. Burke and Gwenith G Fisher and Fultz, Nancy H. and Michael D Hurd and Guy G Potter and Willard L Rodgers and David C Steffens and David R Weir} } @article {6920, title = {The health effects of restricting prescription medication use because of cost.}, journal = {Med Care}, volume = {42}, year = {2004}, note = {Comment in: Med Care. 2004 Jul;42(7):623-5 AN=15213485}, month = {2004 Jul}, pages = {626-34}, publisher = {42}, abstract = {

BACKGROUND: High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known.

METHODS: We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995-1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression.

RESULTS: In adjusted analyses, 32.1\% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2\% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27-2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9\% vs. 8.2\%; AOR, 1.50; CI, 1.09-2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8\% vs. 5.3\%; AOR, 1.51; CI, 1.02-2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort.

CONCLUSIONS: Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

}, keywords = {Aged, Chronic disease, Female, Financing, Personal, Health Services Accessibility, Health Status, Humans, Male, Middle Aged, Multivariate Analysis, Patient Compliance, Prospective Studies, Risk, United States}, issn = {0025-7079}, doi = {10.1097/01.mlr.0000129352.36733.cc}, author = {Michele M Heisler and Kenneth M. Langa and Eby, Elizabeth L. and A. Mark Fendrick and Mohammed U Kabeto and John D Piette} } @article {6914, title = {Out-of-pocket health-care expenditures among older Americans with cancer.}, journal = {Value Health}, volume = {7}, year = {2004}, month = {2004 Mar-Apr}, pages = {186-94}, publisher = {7}, abstract = {

OBJECTIVE: There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx).

METHODS: We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated.

RESULTS: Of the 6370 respondents, 5382 (84\%) reported No CA, 812 (13\%) reported CA/No Tx, and 176 (3\%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were 1210 dollars, 1450 dollars, and 1880 dollars, respectively (P < .01). Prescription medications (1120 dollars per year) and home care services (250 dollars) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27\% of their yearly income on OOPE compared to only 5\% of yearly income for high-income individuals with no cancer history (P < .01).

CONCLUSIONS: Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer.

}, keywords = {Aged, Aged, 80 and over, Cost of Illness, Family Characteristics, Female, Financing, Personal, Health Expenditures, Health Services Research, Humans, Insurance, Health, Longitudinal Studies, Male, Medicaid, Medicare, Michigan, Neoplasms}, issn = {1098-3015}, doi = {10.1111/j.1524-4733.2004.72334.x}, author = {Kenneth M. Langa and A. Mark Fendrick and M.E. Chernew and Mohammed U Kabeto and Paisley, Kerry L. and Hayman, James A.} }