The Clinical Management of Early Alzheimer's Disease

A Handbook

Reinhild Mulligan, Martial Van der Linden, Anne-Claude Juillerat

• Publisher: Psychology Press
• Year: 2013
• ISBN:
  9781135665852
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The enormous human and economic toll of Alzheimer's Disease in societies in which more and more people are living into old age is well-recognized. Scientists and practitioners alike have been working to limit it. Their major focus has been patients in the later stages of the disease, when dementia is fully established. Yet patients in the early stages of cognitive decline, far more numerous, often still living independently with family members, present a bewildering variety of challenges. Bringing together leading authors with diverse expertise, this Handbook offers the first comprehensive overview of approaches to the management of early-stage issues. The authors summarize the important implications of the latest research in their own fields for:
* the recognition and formal diagnosis of cognitive problems;
* the assessment of specific difficulties in daily functioning;
* the formulation of a management plan integrating pharmacological, neuropsychological, behavioral, and cognitive strategies; and
* the facilitation and support of caregivers' efforts. All professionals involved in any way with the care of early Alzheimer's patients and their families will find this book an indispensable reference.

1

Sociodemographic and Economic Aspects

Jean-Pierre Michel

Gabriel Gold

François Herrmann

Dina Zekry

Reinhild Mulligan

Panteleimon Giannakopoulos

University Hospitals of Geneva

“Dementia is certainly one of the most dramatic medical and economic challenges that our society will face in the coming years”

—Souêtre et al., 1995

Dementia is a superordinant category of illness that includes all conditions causing loss of cognitive abilities in an individual who was previously intellectually normal (or was functioning at a higher level) and that are not accounted for by an acute illness causing delirium (Geldmacher & Whitehouse, 1996). Dementia is a slowly progressive, currently incurable, long-lasting disease (Whitehouse, 1997) that ranks very high in the global burden of diseases. In 1994, the incidence of dementia was the ninth most frequent among all disorders (959,000 cases per year) in the United States, and its prevalence ranked eighth (7,082,000 cases; Murray & Lopez, 1997). In most industrialized countries the prevalence of Alzheimer’s Disease (AD), the most common dementing disorder, varies between 6% and 8% of persons older than 65. In every decade after the sixth, the number of patients suffering from AD approximately doubles (Katchaturian & Radebaugh, 1998), with an estimated 30% of the population older than 85 years of age affected by it (Ritchie & Kildea, 1995). AD and other degenerative dementias have a drastic impact on the lives of patients and on family members who serve as caregivers for these patients (Cayton, 1993; Coon & Edgerly, 1999). Moreover, dementia induces enormous health care costs, which will increase more rapidly in an aging society (Meerding, Bonneux, Polder, Koopmanschap, & van der Maas, 1998). In the United States, the annual direct costs of treating AD were estimated to be $21 billion in 1991 (Ernst & Hay, 1994) and $29.8 billion in 1998 (Menzin, Lang, Friedman, Neumann, & Cummings, 1999). In the Netherlands in 1994, dementia ranked third in total health care costs (5.6% with 7.4% for women and 2.9% for men), first in the 65–84 age group (9.5%), and first in the over 85 age group (22.2%; Meerding et al., 1998). In the early stages of the disease, major costs stem from the loss of patient’s and caregiver’s productivity and from family out-of-pocket expenses (Schumock, 1998). In the advanced stages of the disease, costs are mainly linked to long-term and institutional care (Menzin et al., 1999). Until now, escalating health care costs were for care and not for cure (Meerding et al., 1998) of an increasing number of affected people (Katchaturian & Radebaugh, 1998). The expected impact of new drug developments may result in not only an improvement of the patient’s cognitive functioning and quality of life but also a reduction in the time spent by caregivers, a delay in nursing home placement, and a reduction of indirect costs (Schumock, 1998). But the current goal is to obtain rapidly a 5-year delay in the onset of the disease, which could reduce the number of patients by 50% (Katchaturian & Radebaugh, 1998). For these reasons, the economic evaluation of AD and related dementia will play an increasingly influential role in clinical and resource allocations in the coming years. Physicians and other health care professionals should familiarize themselves with techniques of cost-effectiveness analysis (Neumann, Herrmann, Berenhaum, & Weinstein, 1997), and this is the aim of this chapter.

Dementia Costs: How to Understand Economic Analysis

Pharmacoeconomics is a new area of health economics that emerged in the late 1970s, arising from concerns about the relative effectiveness and costs of different drugs (Bootman, Townsend, & McGhan, 1996; Spilker, 1996). The term pharmacoeconomics may have first been used in 1986 in reference to postmarketing drug research. Pharmacoeconomics dealt first with preventive strategies, such as immunization and screening programs, and later with the treatment of acute illnesses, such as antibodies use in burn patients and antibiotic use for different types of infections (Whitehouse, 1997). Until a few years ago chronic conditions such as dementia suffered from a lack of both theoretical and empirical developments in this field (Whitehouse, 1997). However, the use of “dementia costs” as key words for Medline research now allows us to identify more than 800 papers published in peer reviewed journals in the last 5 years that are devoted to economic considerations of AD.

Researchers must consider both societal and specific payer’s perspectives. From the societal perspective, all relevant costs are included. From the perspective of the specific payer (e.g., patients, families, insurance companies, municipality, county), various selected costs are included or excluded (Winblad, Hill, Beermann, Post, & Wimo, 1997).

Three main types of analysis can be identified (see Table 1.1).

Table 1.1 Various Types of Cost Analysis Applied to Dementia

Type	Description
Economic burden
Cost of illness (Winblad et al., 1997)	Description of all relevant costs of a particular disease (dementia) to a society. Care strategies are not evaluated.
Costs of various care strategies
Cost description (Drummond, Stoddart, & Torrance, 1987)	Analysis of the costs of one type of treatment/care strategy; no comparison with alternative types of treatment/care strategies.
Cost analysis	Comparison of the costs of different therapies/care strategies; not taking into account the effects.
Trade-off analysis between care costs and defined or supposed outcomes
Cost-minimization analysis (CMA)	Comparative cost analysis of two treatments/care strategies estimated to have the same effects.
Cost-benefit analysis (CBA)	Analysis of all costs achieved by one treatment/care strategy with good outcome; same monetary unit.
Cost-effectiveness analysis (CEA)	Analysis of all costs achieved by one treatment/care strategy with good outcome; nonmonetary unit.
Cost-utility analysis (CUA; Torrance, 1987)	Analysis of all costs of a therapy/care strategy with a single important outcome, such as quality of life.
Pharmacoeconomics	Could be part of types II and III analysis.
Cost consequence	Outcomes and costs of a specific treatment are measured together in the same indirect mathematical analysis.

Note: Adapted from Wimo et al. (1997). Costs of dementia and dementia care: A review. International Journal of Geriatric Psychiatry, 12. Also adapted from Winblad et al. (1997). Issues in the economic evaluation of treatment for dementia: Position papers from the international working group on harmonization of dementia drug guidelines. Alzheimer Disease and Associated Disorders, 11.

The economic burden analysis of a disease (i.e., cost of illness) is estimated by counting all relevant costs of a particular disease to a society, without any consideration as to which care strategies are used. This kind of analysis is very complicated and is valuable only for social and health policy discussions (Winblad et al., 1997).

Cost analysis of various care strategies includes cost description and cost analysis. Cost description analysis is an economic analysis of only one type of treatment or care, without making any comparisons with alternative types of treatment or care (Drummond, Stoddart, & Torrance, 1987). Cost analysis compares different therapies/treatments but does not compare the effect of these treatments. A large majority of economic studies of dementia care are of this type, and many have their origin in a local project or program. Home care costs (Dellasega & King, 1996; Rice et al., 1993; Souêtre et al., 1995; Stommel, Collins, & Given, 1994), day care costs or intermediate care alternatives (Knapp, Wilkinson, & Wigglesworth, 1998; Wimo, Ljunggren, & Winblad, 1997; Wimo, Mattson, Krakau, Eriksson, & Nelvig, 1994a, 1994b; Wimo et al., 1997), nursing home costs (Ernst & Hay, 1994; Fries, Mehr, Schneider, Foley, & Burke, 1993; Ljunggren & Brandt, 1996; Rovner, Steele, Shmuley, & Folstein, 1996), and special care units (Holmes, Ory, & Teresi, 1994; Volicer et al., 1994) have been analyzed differently. Four methodological strategies were used: Detailed cost analysis, average costs, longitudinal cost analysis of patients’ care, and cost comparison with other types of care.

Trade-off analysis between care costs and defined or supposed outcomes include cost-minimization, cost-benefit, cost-effectiveness and cost-utility analyses. Cost-minimization analysis (CMA) compares the costs with a final recommendation of the use of the cheaper, assuming equivalent effects of the two treatments or care strategies. This type of analysis fulfills criteria for complete health economic studies. However, it is currently rarely used and is recommended for future studies. Cost-benefit analyses (CBA) and cost-effectiveness analysis (CEA) correspond respectively to the same monetary and nonmonetary analysis of all costs linked to a therapy/care strategy with an expected precise outcome. CEA shows the relationship between all resources used and the health benefit achieved (i.e., the effects) of one intervention (Neuman et al., 1997, 1999). CEA is a possible solution for evaluating informal care (shadow price method) and for considering the patient’s quality of care (Busschbach, Brouwer, van der Donk, Passchier, & Rutten, 1998). Cost-utility (CUA) analysis considers the cost of a care treatment/strategy, considering one single important outcome, such as the patient’s quality of life (Torrance, 1987). CUA shows the relationship between weights or utility weights (quality-adjusted life years or quality) for particular outcomes and quality of life (Albert et al., 1996). The use of generic scales could allow comparison with other diseases (Winblad et al., 1997).

Pharmacoeconomics, in the strictest sense, could be part of the previous types of analyses. However, pharmacoeconomics also includes cost-consequences analysis, which corresponds to consumer preferences/satisfaction (with an indirect mathematical analysis) of outcome and costs of a specific treatment/health service (Whitehouse, 1997). For example, the cost-effectiveness of the new dementia drugs (acetylcholine esterase inhibitors, AchE I) includes not only the price of the drug but also its ability to stabilize or improve the patient’s and caregiver’s quality of life and reduce caregiving costs (Ernst & Hay, 1994; see Table 1.2). This kind of analysis is complex because it must include data and costs that vary constantly, such as delay of institutionalization, reduction in number of hours of informal caregiving required by the patient, improvement of quality of life for patients and caregivers, and that need to be compared with societal trends and progress (Souêtre et al., ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• Foreword
• Preface
• List of Contributors
• 1. Sociodemographic and Economic Aspects
• 2. Clinical Aspects
• 3. Cognitive-Neuropsychological Aspects
• 4. Assessment: The Multidisciplinary Approach
• 5. The Role of Memory Clinics in Diagnosis and Management
• 6. Pharmacological Treatment: Recent Developments
• 7. Psychiatric and Behavioral Problems: Pharmacological Approaches
• 8. Psychiatric and Behavioral Problems: Psychosocial Approaches
• 9. Cognitive Intervention
• 10. The Assessment of Functioning in Daily Life
• 11. The Role of Caregivers in Assessment and Intervention
• 12. Taking Care of the Caregivers
• Author Index
• Subject Index