Purpose: The forceful consequence of dementia was referred to as a “tidal wave” at the First World Health Organization (WHO) Ministerial Conference on Global Action Against Dementia in Geneva, Switzerland, where it was estimated that 47.5 million people worldwide have dementia, and that number is expected to double every 20 years.
Today in the United States there are 5 million people living with Alzheimer’s Disease (AD) alone, with the number projected to rise to some 14 million by 2050. The estimated impact of the Baby Boomers over the next 35 years is that nearly 30 million will develop AD. Despite the massive impact of those currently counted as having a dementing illness, the actual incidence of cognitive impairment enumerated above may be only the tip of the dementia iceberg. It is estimated that 27%-81% of cognitive impairment is unacknowledged in primary care settings. American nursing facilities already provide a glimpse into the future of the population at large. There are 1.35 million individuals living in nursing homes in the U.S., and nearly half (48%) of nursing home residents have Alzheimer’s disease and related dementias (ADRD) and 68% in 2009 had some degree of cognitive impairment.
The challenges associated in those individuals who have dementia strain health and long-term care systems. This stress will only intensify for Medicare, Medicaid and other involved payers as the number of elders, and the resultant population of ADRD, grows over the next decades. They utilize a disproportionate amount of healthcare resources. They are hospitalized 2-3 times as often as people the same age who do not have the disease. There is a significant association for Medicare beneficiary hospitalization in those with dementia across chronic disease comorbidities and disease pairings. Those with dementia have an increased number of comorbidities along with and more serious comorbidity. Healthcare costs for persons with dementia are more than 80% higher than those for people with heart disease or cancer in one study, with the costs over the last five years of life for patients with dementia of $287,038. A likely source of enhanced costs in those with dementia is the higher incidence of transitions with the resultant hospitalizations, duplicative testing, adverse drug events, delirium and other eventualities due in part to deficient handoffs between care sites or due to unnecessary transitions in care site. Older adults with prevalent or incident dementia had higher Medicare and Medicaid nursing facility use, greater hospital and home health care utilization, more transitions per person-year and more mean total transitions that those never diagnosed with dementia. Additionally, of those with dementia with a rehospitalization with 30 days, 45% had been discharged to nursing facilities from the index hospitalization.
This paper will focus on dementia, reflecting permanent cognitive loss. It is anticipated that the principles here can be extrapolated to other disorders that affect cognition.
Authors: Robert Burke, MD, MS; Cari Levy, MD, PhD, CMD; H. Edward Davidson, PharmD, MPH; Kenneth Boockvar, MD, MS; Karl Steinberg, MD, CMD; Wayne Saltsman, MD, PhD, CMD; Susan M. Levy MD, CMD, AGSF; Jose Gonzalez, MD, CMD; Rod Baird, MS; Manisha Parulekar, MD, CMD; James E. Lett, II, MD, CMD