<p>Being the spouse of a person with dementia can be a significant source of strain and can negatively impact one's health.<span><sup>1</sup></span> Although not all spouses serve as the primary caregiver, many spouses provide physical or emotional support to the person with dementia. Studies have shown that spouses of persons with dementia are more likely to have depression, anxiety, and sleep disturbances compared with spouses of persons who do not have dementia.<span><sup>2-4</sup></span> Identifying opportunities to improve health among spouses of persons with dementia is essential. In the United States, families provide most of the long-term care to persons with dementia.<span><sup>1</sup></span> Family members need to maintain sufficient health to fulfill caregiving roles and responsibilities to sustain this system. Spouses of a person with dementia may have less time and fewer financial resources to participate in recommended health behaviors and receive healthcare services, which, over time, may impact their ability to care for the person with dementia.<span><sup>5</sup></span></p><p>In this issue, <i>Ingraham</i> et al. present the results of a matched study examining Medicare Fee-for-Service expenditures for spouses of persons living with dementia compared with spouses of persons without dementia in the 5 years after the person with dementia was diagnosed with dementia.<span><sup>6</sup></span> Using the Health and Retirement Study with linked Medicare Claims, the authors measured three categories of health utilization costs: (1) inpatient or hospital expenditures; (2) outpatient or ambulatory expenditures, which included emergency room visits if a hospitalization did not follow the visit; and (3) skilled nursing facility, hospice, and home health expenditures. In the adjusted analysis, there was no difference in total Medicare expenditures between spouses of persons with dementia and spouses of persons without dementia in the 5 years after dementia was diagnosed. However, in Year 5, there was an increase in total Medicare expenditures among spouses of persons living with dementia driven by an increase in inpatient expenditures, with a total difference of $2748 (95% CI $321–$5447).</p><p>The results of this study differ from prior matched studies examining healthcare expenditures among spouses of persons living with dementia.<span><sup>3, 4, 7, 8</sup></span> As the authors note, prior studies had relied on claims data to identify persons with dementia, while the methods used by <i>Ingraham</i> et al. for identifying incident diagnoses of dementia from the Health and Retirement Study identified adults at an earlier stage of the disease. However, several other differences existed between this study and prior published studies. These include the methods by which spouses were identified, the type of insurance the spouse had, and the types of expenditures included in the total expenditures.<span><sup>3, 4, 7, 8</sup></span> In addition, <i>
{"title":"More than dollars: Healthcare utilization among spouses of persons with dementia","authors":"Molly J. Horstman MD, MS","doi":"10.1111/jgs.19174","DOIUrl":"10.1111/jgs.19174","url":null,"abstract":"<p>Being the spouse of a person with dementia can be a significant source of strain and can negatively impact one's health.<span><sup>1</sup></span> Although not all spouses serve as the primary caregiver, many spouses provide physical or emotional support to the person with dementia. Studies have shown that spouses of persons with dementia are more likely to have depression, anxiety, and sleep disturbances compared with spouses of persons who do not have dementia.<span><sup>2-4</sup></span> Identifying opportunities to improve health among spouses of persons with dementia is essential. In the United States, families provide most of the long-term care to persons with dementia.<span><sup>1</sup></span> Family members need to maintain sufficient health to fulfill caregiving roles and responsibilities to sustain this system. Spouses of a person with dementia may have less time and fewer financial resources to participate in recommended health behaviors and receive healthcare services, which, over time, may impact their ability to care for the person with dementia.<span><sup>5</sup></span></p><p>In this issue, <i>Ingraham</i> et al. present the results of a matched study examining Medicare Fee-for-Service expenditures for spouses of persons living with dementia compared with spouses of persons without dementia in the 5 years after the person with dementia was diagnosed with dementia.<span><sup>6</sup></span> Using the Health and Retirement Study with linked Medicare Claims, the authors measured three categories of health utilization costs: (1) inpatient or hospital expenditures; (2) outpatient or ambulatory expenditures, which included emergency room visits if a hospitalization did not follow the visit; and (3) skilled nursing facility, hospice, and home health expenditures. In the adjusted analysis, there was no difference in total Medicare expenditures between spouses of persons with dementia and spouses of persons without dementia in the 5 years after dementia was diagnosed. However, in Year 5, there was an increase in total Medicare expenditures among spouses of persons living with dementia driven by an increase in inpatient expenditures, with a total difference of $2748 (95% CI $321–$5447).</p><p>The results of this study differ from prior matched studies examining healthcare expenditures among spouses of persons living with dementia.<span><sup>3, 4, 7, 8</sup></span> As the authors note, prior studies had relied on claims data to identify persons with dementia, while the methods used by <i>Ingraham</i> et al. for identifying incident diagnoses of dementia from the Health and Retirement Study identified adults at an earlier stage of the disease. However, several other differences existed between this study and prior published studies. These include the methods by which spouses were identified, the type of insurance the spouse had, and the types of expenditures included in the total expenditures.<span><sup>3, 4, 7, 8</sup></span> In addition, <i>","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 10","pages":"2969-2971"},"PeriodicalIF":4.3,"publicationDate":"2024-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.19174","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142116615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Michelle C. Odden PhD, Chintan V. Dave PharmD, PhD
<p>In this issue of the <i>Journal of the American Geriatrics Society</i>, Piexoto et al. conducted a systematic review of studies of statin discontinuation on clinical outcomes.<span><sup>1</sup></span> They identified only one randomized trial of statin discontinuation, conducted in people near the end of life, which found no difference in 60-day mortality or 1-year cardiovascular mortality among people who discontinued statins compared with those who continued statins. In contrast, among 35 nonrandomized studies among people not near the end of life, statin discontinuation was associated with a higher risk of all-cause mortality, cardiovascular mortality, and cardiovascular events. However, the authors noted concerns around bias of confounding by indication, along with concerns about imprecision, inconsistency, and heterogeneity. Together, the findings from observational studies were evaluated as having a high degree of uncertainty and bias, leaving providers and their patients with little useful information outside of the end-of-life setting.</p><p>There is discordance among the major Northern American and European guidelines on the evaluation of the benefit of statins in older adults, especially for primary prevention.<span><sup>2</sup></span> This is compounded by the challenge of accurate prediction of cardiovascular events in older adults, as a risk-based prevention strategy is the cornerstone of many of the guideline recommendations. Adding to the complexity, there is also insufficient evidence to capture potential harms of statin use due to the limited representation of older adults in large randomized statin trials. Further, limited evidence on statins and patient-centered outcomes such as frailty or statin-associated physical or cognitive changes exists, although one modestly sized trial demonstrated worsening decline in energy and exertional fatigue among persons randomized to statins.<span><sup>3</sup></span> Taken collectively, these factors have contributed to a growing interest in medication discontinuation or dose reduction, otherwise referred to as deprescribing, of statins in older adults.</p><p>Piexoto aimed to address this evidence gap by synthesizing the evidence for statin discontinuation, but their systematic review only highlights the challenges in estimating medication effects in observational studies.<span><sup>1</sup></span> Despite recent advancements in observational research methodologies, the majority of studies included in the review were assessed to have a serious risk of bias. The primary limitation of observational studies, in contrast to randomized trials, is that of confounding, or which occurs when the populations who discontinue statins are systematically different than those who continue statins. This limitation is especially challenging for studies of medication deprescribing and mortality, as limited life expectancy is a common reason for medication review and deprescribing.<span><sup>4</sup></span> The
{"title":"Many studies, but little certainty about the effects of statin discontinuation on outcomes","authors":"Michelle C. Odden PhD, Chintan V. Dave PharmD, PhD","doi":"10.1111/jgs.19157","DOIUrl":"10.1111/jgs.19157","url":null,"abstract":"<p>In this issue of the <i>Journal of the American Geriatrics Society</i>, Piexoto et al. conducted a systematic review of studies of statin discontinuation on clinical outcomes.<span><sup>1</sup></span> They identified only one randomized trial of statin discontinuation, conducted in people near the end of life, which found no difference in 60-day mortality or 1-year cardiovascular mortality among people who discontinued statins compared with those who continued statins. In contrast, among 35 nonrandomized studies among people not near the end of life, statin discontinuation was associated with a higher risk of all-cause mortality, cardiovascular mortality, and cardiovascular events. However, the authors noted concerns around bias of confounding by indication, along with concerns about imprecision, inconsistency, and heterogeneity. Together, the findings from observational studies were evaluated as having a high degree of uncertainty and bias, leaving providers and their patients with little useful information outside of the end-of-life setting.</p><p>There is discordance among the major Northern American and European guidelines on the evaluation of the benefit of statins in older adults, especially for primary prevention.<span><sup>2</sup></span> This is compounded by the challenge of accurate prediction of cardiovascular events in older adults, as a risk-based prevention strategy is the cornerstone of many of the guideline recommendations. Adding to the complexity, there is also insufficient evidence to capture potential harms of statin use due to the limited representation of older adults in large randomized statin trials. Further, limited evidence on statins and patient-centered outcomes such as frailty or statin-associated physical or cognitive changes exists, although one modestly sized trial demonstrated worsening decline in energy and exertional fatigue among persons randomized to statins.<span><sup>3</sup></span> Taken collectively, these factors have contributed to a growing interest in medication discontinuation or dose reduction, otherwise referred to as deprescribing, of statins in older adults.</p><p>Piexoto aimed to address this evidence gap by synthesizing the evidence for statin discontinuation, but their systematic review only highlights the challenges in estimating medication effects in observational studies.<span><sup>1</sup></span> Despite recent advancements in observational research methodologies, the majority of studies included in the review were assessed to have a serious risk of bias. The primary limitation of observational studies, in contrast to randomized trials, is that of confounding, or which occurs when the populations who discontinue statins are systematically different than those who continue statins. This limitation is especially challenging for studies of medication deprescribing and mortality, as limited life expectancy is a common reason for medication review and deprescribing.<span><sup>4</sup></span> The","PeriodicalId":17240,"journal":{"name":"Journal of the American Geriatrics Society","volume":"72 11","pages":"3291-3293"},"PeriodicalIF":4.3,"publicationDate":"2024-08-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11560708/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142116614","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}