This week, a great team of researchers released a fascinating paper in JAMA Internal Medicine##. They asked a simple question: Do people who are at some point diagnosed with Alzheimer’s disease and related dementias (ADRD) display declining cognition in their financial management before diagnosis.
Results Overall, 54 062 (17 890 [33.1%] men; mean [SD] age, 74 [7.3] years) were never diagnosed with ADRD during the sample period and 27 302 had ADRD for at least 1 quarter of observation (8573 [31.4%] men; mean [SD] age, 79.4 [7.5] years). Single Medicare beneficiaries diagnosed with ADRD were more likely to miss payments on credit accounts as early as 6 years prior to diagnosis compared with demographically similar beneficiaries without ADRD (7.7% vs 7.3%; absolute difference, 0.4 percentage points [pp]; 95% CI, 0.07-0.70:) and to develop subprime credit scores 2.5 years prior to diagnosis (8.5% vs 8.1%; absolute difference, 0.38 pp; 95% CI, 0.04-0.72). By the quarter after diagnosis, patients with ADRD remained more likely to miss payments than similar beneficiaries who did not develop ADRD (7.9% vs 6.9%; absolute difference, 1.0 pp; 95% CI, 0.67-1.40) and more likely to have subprime credit scores than those without ADRD (8.2% vs 7.5%; absolute difference, 0.70 pp; 95% CI, 0.34-1.1). Adverse financial events were more common among patients with ADRD in lower-education census tracts. The patterns of adverse events associated with ADRD were unique compared with other medical conditions (eg, glaucoma, hip fracture).
Okay, this is just a wicked cool idea and study.
I’ve been spending a lot of my non-COVID related headspace on the challenges of choice in the ACA marketplaces. Choosing insurance under the best of circumstances is tough. There are a lot of things that need to be estimated and assumed and guessed at. There is a lot of language to decipher. There is a lot of edge cases that occur. Insurance choice is, at best, a challenge.
My wife and I are on traditional Medicare, with no D or supplemental. We are betting that our current good health (he says while knocking furiously on wood) will continue, which is an unknown. As others have noted above, it’s a crazy complex system for anyone to navigate, but for a population where many have declining mental resources it is problematic.
The study above is strong evidence of pragmatic consequences of a chronic illness that will present well before diagnosis. It is a disease that makes executive management, and complex cognitive choices either more difficult or impossible as it progresses. Early signs of the disease show that routine choices/daily life management are more difficult for people who will eventually be diagnosed with ADRD. ADRD is not an unusual diagnosis. In this study, about a third of the cohort has at least one ADRD diagnosis on at least one claim. ADRD is tough to diagnose.
Yet we expect a population that has significant decision-making challenges due to their health conditions to sort through a complex decision menus to choose their hopefully optimal, or at least satisficing health finance and financial protection product every year.
##Nicholas LH, Langa KM, Bynum JPW, Hsu JW. Financial Presentation of Alzheimer Disease and Related Dementias. JAMA Intern Med. Published online November 30, 2020. doi:10.1001/jamainternmed.2020.6432