Implications of Racial Differences in the Shifts in the Setting of Care for Alzheimer’s Disease and Related Dementias

Abstract The prevailing setting of care has strong associations with the progression of a disease at time of first diagnosis, subsequent treatment, resulting health outcomes as well as both long-term and short-term costs. The care of Alzheimer’s Disease (AD) and Related Dementias (ADRD) has been experiencing a shift from skilled nursing facility to home health care. However, changes in practice do not disseminate equally across the race/ethnicity spectrum of the U.S. and disadvantaged race/ethnicity-related groups often encounter differing conditions from those experienced by the majority. In this study, we calculated the race/ethnicity-related direct healthcare costs of individuals with AD and ADRD, stratified by care-provider structure (physician, inpatient, outpatient, skilled nursing facility, home health, hospice), and modeled the trends and the relative contributions of each setting over the 1991-2017 period using administrative claims from a 5% sample of Medicare beneficiaries. Inflation and the gradual switch of Medicare compensation to the HCC model between 2004 and 2007 were accounted for. We then applied an inverse probability weighting algorithm to propensity-score-match the AD/ADRD race/ethnicity-specific groups to Medicare beneficiaries to make them comparable in demographics and co-morbidity status but without AD/ADRD. Finally, we performed a comparison of the Medicare costs and associated survival within (AD/ADRD vs. No AD/ADRD) and between (Black vs. White vs. Hispanic) race/ethnicity-related groups. Comparisons were done for: i)1-year before; ii) 1-year after iii) years 2-11; iv)years 12-21 and v) years 22+ after an AD/ADRD diagnosis. We found significant race/ethnicity-related differences in costs and survival both before and after propensity score matching.

is limited research on using EHR to identify persons with Alzheimer's disease (AD) and related dementias (RD).In a data-driven approach, we used all ICD-9 diagnosis and CPT procedure codes from statewide inpatient, ambulatory surgery, and Medicare records, in addition to age at baseline and gender, to detect AD/RD from the Cache County Study on Memory in Aging (1995Aging ( -2009)).After removing participants diagnosed with dementia at baseline (n=335), 3882 (82%) Cache County Study participants could be linked to inpatient, ambulatory surgery, and/or Medicare EHR records; 484 (12.5%) of these 3882 had incident all-cause dementia, with 308 (7.9%) having AD/AD comorbid with RD; and 176 (4.5%) having RD without AD.We removed participant's ICD-9 codes occurring after first AD/RD diagnoses.EHR features (~2000) along with gold-standard diagnoses as class labels were then used to train and detect AD and/or RD using a Gradient Boosting Trees machine learning algorithm.Models evaluated with nested cross-validation yielded AUCs of 0.70 for all-cause dementia, 0.69 for AD/ AD comorbid with RD, and 0.67 for RD without AD.Key factors detecting AD/RD included age at enrollment, cardiovascular, metabolic, and kidney disease, and sleep disturbances, with feature importance varying by record type and time frame prior to dementia onset.Our findings suggest that a patient's health status up to 12 years prior may be useful in identifying individuals at-risk for dementia development.

EFFECTS OF CAREGIVER INTERVENTIONS FOR INFORMAL CAREGIVERS OF OLDER ADULTS WITH COGNITIVE DECLINE Machiko Tomita, University at Buffalo, Buffalo, New York, United States
Objectives: To identify baseline factors and process factors, which indicate changes that are associated with caregiving confidence improvement attributed to caregiver support.
Methods: An intervention study using 35 informal caregivers (ICG) of older adults (≥65 years old) with cognitive decline.Recipients of ICGs belonged to the Programs of All Inclusive Care for the Elderly (PACE).Interventions were occupational therapy (OT) support or education about illness and effective caregiving methods, which took place in ICGs' homes.OT interventions included training to reduce physical strain, and improve time and task organizations, and providing assistive devices).Caregiver confidence was measured using a Visual Analog Scale.Data were divided into two groups: improved confidence and decreased/no-change confidence.Eleven baseline data of care recipients (CRs) and ICGs as well as five process data were analyzed using logistic regression.
Results: Baseline factors that differentiated the two groups were ICG's age, caregiving confidence level, and CR's cognitive status, of which classification accuracy was 94.3%.Only Zarit Buren Interview (ZBI) score was associated with caregiving confidence change, of which classification accuracy was 74.3%.Younger ICGs, lower cognition, and lower caregiving confidence among baseline factors, and improved ZBI among the process factors were associated with improved confidence.
Discussion: Although our interventions prevented 65.7% of caregivers form declining their caregiving confidence, improving caregiving confidence was difficult while CRs' cognition continued to decline.However, this positive change was possible even CRs had moderate dementia, on average.Personal interventions may be necessary to improve caregiving confidence and reduce ICG's burden.Theresa Scott, 1 Ying-Ling Jao, 2 Kristen Tulloch, 1  Yates Eloise, 1 and Nancy Pachana, 1 1 The majority of people living with dementia in the early and middle stages are cared for at home by family caregivers.Participation in meaningful activities is important for good quality of life.Recreation based on horticulture is beneficial for people living with dementia in residential settings, yet evidence within community settings is less clear.The aim of this research was to examine the existing evidence for the impact of using contact with nature, gardens and plants to enhance well-being of people living with dementia in the community.Our secondary aim was to explore the outcome domains and instruments that were employed in the existing research studies, to inform future research efforts and guide clinical practice.A systematic search was conducted covering several databases and gray literature.Original studies that examined group or individual horticulture-based activities or interventions were included.Of 2127 articles identified through searching, 10 were selected for full review.The findings reveal that horticulture-based intervention showed positive impacts on food intake, social interaction, and well-being in older adults with dementia.Some evidence shows that horticulture-based activities may alleviate stressful symptoms associated with living with dementia.Future research may further evaluate the effect of the interventions on cognitive function, physical function, and behavioral symptoms in a more rigorous intervention design.The prevailing setting of care has strong associations with the progression of a disease at time of first diagnosis, subsequent treatment, resulting health outcomes as well as both long-term and short-term costs.The care of Alzheimer's Disease (AD) and Related Dementias (ADRD) has been experiencing a shift from skilled nursing facility to home health care.However, changes in practice do not disseminate equally across the race/ethnicity spectrum of the U.S. and disadvantaged race/ethnicity-related groups often encounter differing conditions from those experienced by the majority.In this study, we calculated the race/ethnicity-related direct healthcare costs of individuals with AD and ADRD, stratified by care-provider structure (physician, inpatient, outpatient, skilled nursing facility, home health, hospice), and modeled the trends and the relative contributions of each setting over the 1991-2017 period using administrative claims from a 5% sample of Medicare beneficiaries.Inflation and the gradual switch of Medicare compensation to the HCC model between 2004 and 2007 were accounted for.We then applied an inverse probability weighting algorithm to propensity-score-match the AD/ADRD race/ ethnicity-specific groups to Medicare beneficiaries to make them comparable in demographics and co-morbidity status but without AD/ADRD.Finally, we performed a comparison of the Medicare costs and associated survival within (AD/ ADRD vs.No AD/ADRD) and between (Black vs. White vs. Hispanic) race/ethnicity-related groups.Comparisons were done for: i)1-year before; ii) 1-year after iii) years 2-11; iv) years 12-21 and v) years 22+ after an AD/ADRD diagnosis.We found significant race/ethnicity-related differences in costs and survival both before and after propensity score matching.

INCIDENCE OF MILD COGNITIVE IMPAIRMENT, CONVERSION TO PROBABLE DEMENTIA, AND MORTALITY
Yun Zhang, 1 Ginny Natale, 2 and Sean Clouston, 3  Background: Few studies have jointly estimated incidence of MCI, conversion to probable dementia, and mortality.
Methods: We used data from six waves of the National Health and Aging Trends Study (2011Study ( -2016)).Multivariableadjusted multi-state survival models (MSMs) were used to model incidence upon accounting for misclassification.
Results: A total of 6,078 eligible NHATS participants 65 years of age and older were included (average age: 77.49±7.79 years; 58.42% females; 68.99% non-Hispanic White).Incidence of MCI was estimated to be 41.0 [35.5, 47.3]/1,000 person-years (PY).Participants converted to probable dementia at a high rate of 241.3 [189.6, 307.0]/1,000PY, though a small number also reverted from MCI to cognitively normal.Education was associated with lower incidence of MCI and probable dementia, but increased mortality in those with MCI.There were also substantial racial and ethnic disparities in the incidence of MCI and dementia.
Conclusions: Our results underscore the relatively common incidence of and conversions between MCI and dementia in community-dwelling older Americans and uncover the beneficial impact of education to withstand cognitive impairment before death.

MACHINE LEARNING-BASED PREDICTIVE MODELS OF BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA
Eunhee Cho, 1 Sujin Kim, 2 Seok-Jae Heo, 3 Jinhee Shin, 1 Byoung Seok Ye, 2 Jun Hong Lee, 4 and Bada Kang, 1 , 1. Yonsei University College of Nursing,Seoul,Seoult'ukpyolsi,Republic of Korea,2. Yonsei University,Seoul,Republic of Korea,3.Yonsei University Graduate School, Seoul, Seoul-t'ukpyolsi, Republic of Korea, 4. National health insurance service Ilsan hospital, Goyang, Kyonggi-do, Republic of Korea Models predicting the occurrence of specific types of behavioral and psychological symptoms of dementia (BPSD) can be highly beneficial for its early intervention and individualized care planning.Using a machine learning approach, this study developed and validated predictive models of the occurrence of BPSD, categorized into seven subsyndromes, among community-dwelling older adults with dementia in South Korea.BPSD dairy was used to measure BPSD and the state of unmet needs daily.We measured sleep and activity levels using actigraphy, and stress and fatigue using a portable heart rate variability analyzer.We developed predictive models and conducted cross-validation using training data that consisted of the first two wave dataset, and then validated the models using wave 3 test data.To deal with imbalanced datasets, we used Synthetic Minority Oversampling Technique (SMOTE), an over-sampling method.Categorical variables were preprocessed using target encoding.We then compared the machine-learning models with logistic regression.The area under the receiver operating characteristic curve (AUC) scores of the support vector machine (SVM) models for the wave 3 test data showed a similar or greater value than logistic regression models across all BPSD subsyndromes.The SVM model (AUC = 0.899) had an AUC value greater than that of the logistic regression model (AUC = 0.717), particularly for hyperactivity symptoms.Machine learning algorithms, especially SVM models, can be used to develop BPSD prediction models to help identify at-risk individuals and implement symptom-targeted individualized interventions.Over ninety percent of people with dementia (PWD) experience behavioral and psychological symptoms, known to increase burden on care providers and healthcare systems.The purpose of this integrative review was to examine the modifiable risk factors of behavioral and psychological symptoms of dementia (BPSD) at the individual, caregiver, and environmental levels.An electronic database search was performed using PubMed, CINAHL[EBSCO], Web of Science, and PsycINFO from 2010-2020.Search terms included "dementia" AND ("Behavioral" OR "Behavioural" OR "Psychological" OR "Neuropsychiatric") AND "symptoms" AND ("Independent Living" OR "Community Dwelling" OR "Community Living" OR "Living at Home" OR "Ageing in Place."The search yielded 1,121 articles, and 14 articles were included in this review.Among the 14 articles, there were 11 modifiable risk factors presented across the individual, caregiver, and environmental levels.Individual-level factors included the presence of affective disorder, low quality of life, and leisure dysfunction.The modifiable caregiver-level factors included relationship with PWD, frequency of contact, caregiver burden, distress, frustration level, caregiver as a resource for PWD, and quality of dyadic relationship.One environmental factor, the presence of pandemic disease (e.g.,