Agency for Healthcare Research and Quality.

Objectives-To evaluate cost-effectiveness of the Tailored Activity Program (TAP) for individuals with dementia and family caregivers.Design-Cost-effectiveness study of a two-group randomized controlled trial involving 60 patientscaregiver dyads randomized to intervention or wait-list control. Setting-Participants' homes in Philadelphia region.Participants-Caregivers were ≥21 years, lived with patients and provided ≥4 hours of daily care. Patients had mild to moderate dementia and behavioral symptoms Intervention-8 sessions of occupational therapy over 4-months to identify patients' preserved capabilities, previous roles, habits and interests, develop customized activities, and train families in their use.Measurements-Incremental cost-effectiveness ratios (ICER), expressed as the cost to bring about one additional unit of benefit measured by caregiver hours per day "doing things" and hours per day "being on duty". Decision tree and Monte Carlo analyses tested robustness of the economic models.Results-Average intervention cost was $941.63 per dyad. ICER showed that intervention caregivers saved one extra hour per day "doing things" at a cost of $2.37 per day; and one extra hour per day "being on duty" at a cost of $1.10 per day. Monte Carlo showed that TAP was cost-effective 1 Funded by the National Institute of Mental Health (Grant #R21 MH069425).2 Corresponding author, Director, Jefferson Center for Applied Research on Aging and Health, Thomas Jefferson University, 130 S. 9 th Street, Suite 500, Philadelphia, PA, 19130; voice -215-503-2896; fax-215-923-2475 NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript 79.2% of the time for "doing things" and 79.6% of the time for "being on duty." Varying the cost assumptions did not change cost-effectiveness.Conclusions-Findings suggest that investment in TAP is cost-effective and afforded families an important, limited and highly valued resource, needed time off from caregiving. This nonpharmacologic approach should be considered part of the clinical management of dementia. KeywordsQuality of life; Caregivers; Behavioral symptoms; Dementia care; Willingness-to-pay OBJECTIVEDementia is a major public health concern with considerable costs to society and family caregivers. In the United States, care costs for individuals requiring daily oversight has been estimated to be as high as $152 billion, a considerable proportion of which ($97 billion), is associated with informal or family caregiving costs. 1,2,3 One of the most costly aspects of providing care to individuals with dementia is managing behavioral symptoms. 4 Behaviors such as agitation, aggressiveness, or resistance to care, are customary, occur throughout disease stages, cause intense family upset, heighten risk of nursing home placement, and increase the need for caregiver time in oversight and management. [5][6][7][8] Behavioral symptoms also significantly increase health utilization and direct care costs such that even a one-point worsening on the Neuropsychiatric Inventory, a c...

Objective To estimate the cost of dementia and the extra cost of caring for someone with dementia compared to someone without dementia. Design We developed an evidence-based mathematical model to simulate disease progression for newly diagnosed individuals with dementia. Data driven trajectories of cognition, function, and behavioral/psychological symptoms were used to model disease progression and predict costs. Using modeling, we evaluated lifetime and annual costs among those with dementia, compared costs between those with and without dementia clinical features, and evaluated the effect of reducing functional decline or behavioral/psychological symptoms by 10% for 12 months (implemented when Mini-Mental State Examination≤21). Setting Mathematical model. Participants Representative simulated US incident dementia cases. Measurements Value of informal care, out-of-pocket expenditures, Medicaid expenditures, and Medicare expenditures. Results From time of diagnosis (mean age of 83 years) discounted total lifetime cost of care for a person with dementia was $321,780 (2015 dollars). Families incurred 70% of the total cost burden ($225,140). Medicaid accounted for 14% ($44,090) and Medicare accounted for 16% ($52,540) of total cost, respectively. Costs for a person with dementia over a lifetime were $184,500 greater (86% incurred by families) than for someone without dementia. Total annual cost peaked at $89,000 and net cost peaked at $72,400. Compared to natural disease progression, reducing functional decline or behavioral/psychological symptoms by 10% resulted in $3,880 and $680 lower lifetime costs, respectively. Conclusion Dementia substantially increases the lifetime costs of care. Long lasting effective interventions are needed to support families as they incur the most dementia cost.

Agency for Healthcare Research and Quality.

Among over 5 million people in the USA with dementia, neuropsychiatric symptoms (NPS) are almost universal, occurring across disease etiology and stage. If untreated, NPS can lead to significant morbidity and mortality including increased cost, distress, depression, and faster disease progression, as well as heightened burden on families. With few pharmacological solutions, , identifying nonpharmacologic strategies is critical. We describe a randomized clinical trial, the Dementia Behavior Study, to test the efficacy of an activity program to reduce significant existing NPS and associated caregiver burden at 3 and 6 months compared to a control group intervention. Occupational therapists deliver 8 in-home sessions over 3 months to assess capabilities and interests of persons with dementia, home environments, and caregiver knowledge, and readiness from which activities are developed and families trained in their use. Families learn to modify activities for future declines and use strategies to address care challenges. The comparison group controls for time and attention and involves 8 in-home sessions delivered by health educators who provide dementia education, home safety recommendations, and advanced care planning. We are randomizing 250 racially diverse families (person with dementia and primary caregiver dyads) recruited from community-based social services, conferences and media announcements. The primary outcome is change in agitation/aggression at 3 and 6 months. Secondary outcomes assess quality of life of persons with dementia, other behaviors, burden and confidence of caregivers, and cost effectiveness. If benefits are supported, this activity intervention will provide a clinically meaningful approach to prevent, reduce, and manage NPS.

Background Effective care models for treating older African Americans with depressive symptoms are needed. Objective To determine whether a home-based intervention alleviates depressive symptoms and improves quality of life in older African Americans. Design Parallel, randomized trial stratified by recruitment site. Interviewers assessing outcomes were blinded to treatment assignment. (ClinicalTrials.gov: NCT00511680) Setting A senior center and participants’ homes from 2008 to 2010. Patients African Americans aged 55 years or older with depressive symptoms. Intervention A multicomponent, home-based intervention delivered by social workers or a wait-list control group that received the intervention at 4 months. Measurements Self-reported depression severity at 4 months (primary outcome) and depression knowledge, quality of life, behavioral activation, anxiety, function, and remission at 4 and 8 months. Results Of 208 participants (106 and 102 in the intervention and wait-list groups, respectively), 182 (89 and 93, respectively) completed 4 months and 160 (79 and 81, respectively) completed 8 months. At 4 months, participants in the intervention group showed reduced depression severity (difference in mean change in Patient Health Questionnaire-9 score from baseline, −2.9 [95% CI, −4.6 to −1.2]; difference in mean change in Center for Epidemiologic Studies Depression Scale score from baseline, −3.7 [CI, −5.4 to −2.1]); improved depression knowledge, quality of life, behavioral activation, and anxiety (P < 0.001); and improved function (P = 0.014) compared with wait-list participants. More intervention than wait-list participants entered remission at 4 months (43.8% vs. 26.9%). After treatment, control participants showed benefits similar in magnitude to those of participants in the initial intervention group. Those in the initial intervention group maintained benefits at 8 months. Limitation The study had a small sample, short duration, and differential withdrawal rate. Conclusion A home-based intervention delivered by social workers could reduce depressive symptoms and enhance quality of life in most older African Americans. Primary Funding Source National Institute of Mental Health.

Evaluating cost effectiveness of interventions for aging in place is essential for adoption in service settings. We present the cost effectiveness of Advancing Better Living for Elders (ABLE), previously shown in a randomized trial to reduce functional difficulties and mortality in 319 community-dwelling elders. ABLE involved occupational and physical therapy sessions and home modifications to address client-identified functional difficulties, performance goals, and home safety. Incremental cost-effectiveness ratio (ICER), expressed as additional cost to bring about one additional year of life, was calculated. Two models were then developed to account for potential cost differences in implementing ABLE. Probabilistic sensitivity analyses were conducted to account for variations in model parameters. By two years, there were 30 deaths (9: ABLE; 21: control). Additional costs for 1 additional year of life was $13,179 for Model 1 and $14,800 for Model 2. Investment in ABLE may be worthwhile depending on society's willingness to pay.

Evidence was insufficient regarding the efficacy of nonpharmacological care-delivery interventions to reduce agitation or aggression in nursing home and assisted living facility residents with dementia.