The study of disparities across diverse populations regarding the health and treatment of patients with osteoarthritis (OA) is recognized as a priority for investigation and action by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the American Academy of Orthopedic Surgeons (AAOS). OA is a common condition that increases with age, but with prevalence generally similar across racial and ethnic groups. However, disparities in the treatment of OA among racial, ethnic, and socioeconomic groups are well-documented and continue to rise and persist. The reasons are complex, likely involving a combination of patient, provider, and healthcare system factors. Treatment disparities among these different populations have an impact on clinical outcomes, healthcare, and productivity, and are projected to increase significantly with the growing diversity of the United States population. The aim of this short review is to summarize studies of racial, ethnic, and socioeconomic disparities among patients with OA in the United States, with a focus on prevalence, treatment utilization, and clinical and economic outcomes.

ObjectivesTo compare medical condition burden, healthcare resource use, and healthcare costs of household members (HHMs) of individuals diagnosed with Alzheimer's disease (AD) with those of HHMs of matched individuals without AD.DesignRetrospective cohort study based on administrative claims data collected between January 1, 2007, and December 31, 2011.SettingMedicare Advantage Prescription Drug (MAPD) plan.ParticipantsMAPD plan members with a diagnosis of AD (International Classification of Disease Ninth Revision, Clinical Modification, code 331.0) were selected and linked to a HHM to form patient-HHM dyads. AD dyads were matched to non-AD dyads.MeasurementsHealth-related endpoints, including medical condition burden, healthcare resource use, and direct healthcare costs, were measured during 36months of continuous health plan enrollment.ResultsIndividuals with AD (n=1,861) were linked to HHMs (n=1,861), and these AD dyads were matched to 1,861 non-AD patient-HHM dyads. AD HHMs had greater medical condition burden scores than non-AD HHMs, with mood disorders, anxiety disorders, insomnia, substance abuse or dependence, cardiovascular disease, and rheumatoid arthritis being more prevalent in AD HHMs. Emergency department and outpatient service use were more common in AD HHMs than in non-AD HHMs, and AD HHMs had greater healthcare costs.ConclusionHHMs of individuals diagnosed with AD demonstrated greater medical condition burden, healthcare resource use, and direct healthcare costs than non-AD HHMs. These findings demonstrate the significant clinical and financial impact of AD on HHMs of individuals with AD.

Background/Rationale: Alzheimer's disease (AD) represents a serious public health issue affecting approximately 5.4 million individuals in the United States and is projected to affect up to 16 million by 2050. This study examined health care resource utilization (HCRU), costs, and comorbidity burden immediately preceding new diagnosis of AD and 2 years after diagnosis. Methods: This study utilized a claims-based, retrospective cohort design. Medicare Advantage members newly diagnosed with AD (n = 3374) were compared to matched non-AD controls (n = 6748). All patients with AD were required to have 12 months of continuous enrollment prior to AD diagnosis (International Classification of Diseases, Clinical Modification [ICD-9] 331.0), during which time no diagnosis of AD, a related dementia, or an AD medication was observed. Non-AD controls demonstrated no diagnosis of AD, a related dementia, or a prescription claim for an AD medication treatment during their health plan enrollment. Medical and pharmacy claims data were used to measure HCRU, costs, and comorbidity burden over a period of 36 months (12 months pre-diagnosis and 24 months post-diagnosis). Results: The HCRU and costs were greater for AD members during the year prior to diagnosis and during postdiagnosis years 1 and 2 compared to controls. The AD members also displayed greater comorbidity than their non-AD counterparts during postdiagnosis years 1 and 2, as measured by 2 different comorbidity indices. Conclusions: Members newly diagnosed with AD demonstrated greater HCRU, health care costs, and comorbidity burden compared to matched non-AD controls.

Approximately 15 million Americans provide unpaid care for individuals with Alzheimer's disease (AD). Over 5 million Americans have AD, and the prevalence is projected to increase dramatically in the coming decades. The impact of AD on family members can be substantial and can impact their well-being. The objective of this research is to compare health-related outcomes among household members (HHMs) of patients with AD to HHMs of individuals without AD. This study is a retrospective cohort study based on administrative claims data collected between January 1, 2007 and December 31, 2011. Non-dual eligible Medicare Advantage Prescription Drug (MAPD) plan members with a diagnosis of AD (ICD-9-CM 331.0) were selected and linked via telephone and address to a HHM in order to form patient-household member dyads. AD dyads were then matched to non-AD dyads, and health-related endpoints including health conditions, service utilization, and direct healthcare costs were measured during 36 months of continuous health plan enrollment. A total of 1,861 individuals with AD were linked to 1,861 household members, and these AD dyads were matched to 1,861 non-AD patient-household member dyads. HHMs in both groups were primarily female (n = 1,080 for both groups, 58.0%), and the mean age was 75 years. The vast majority (n= 1,759, 94.5%) of HHMs linked to subjects with AD were opposing gender. AD HHMs had greater number of health conditions compared to non-AD HHMs, and medical conditions including mood disorders, anxiety disorders, insomnia, substance abuse or dependence, cardiovascular disease, and rheumatoid arthritis were more prevalent among AD HHMs. Compared to non-AD HHMs, emergency department and outpatient utilization was more common among HHMs of individuals with AD, and AD HHMs had greater healthcare costs. Household members of individuals diagnosed with AD demonstrated greater health condition burden, healthcare service utilization, and direct healthcare costs compared to non-AD HHMs. These findings demonstrate the significant clinical and financial impact of AD among household member of patients with AD. Household members and other potential caregivers of individuals with AD should be counseled on the importance of caring for their own physical and psychological well-being.

Variation in brain structure is both genetically and environmentally influenced. The question about potential differences in brain anatomy across populations of differing race and ethnicity remains a controversial issue. There are few studies specifically examining racial or ethnic differences and also few studies that test for race-related differences in context of other neuropsychiatric research, possibly due to the underrepresentation of ethnic minorities in clinical research. It is within this context that we conducted a secondary data analysis examining volumetric MRI data from healthy participants and compared the volumes of the amygdala, hippocampus, lateral ventricles, caudate nucleus, orbitofrontal cortex (OFC) and total cerebral volume between Caucasian and African-American participants. We discuss the importance of this finding in context of neuroimaging methodology, but also the need for improved recruitment of African Americans in clinical research and its broader implications for a better understanding of the neural basis of neuropsychiatric disorders.This was a case control study in the setting of an academic medical center outpatient service. Participants consisted of 44 Caucasians and 33 ethnic minorities. The following volumetric data were obtained: amygdala, hippocampus, lateral ventricles, caudate nucleus, orbitofrontal cortex (OFC) and total cerebrum. Each participant completed a 1.5 T magnetic resonance imaging (MRI). Our primary finding in analyses of brain subregions was that when compared to Caucasians, African Americans exhibited larger left OFC volumes (F (1,68) = 7.50, p = 0.008).The biological implications of our findings are unclear as we do not know what factors may be contributing to these observed differences. However, this study raises several questions that have important implications for the future of neuropsychiatric research.

This report summarizes the findings and recommendations of an expert consensus workgroup that addressed the endangered pipeline of geriatric mental health (GMH) researchers. The workgroup was convened at the Summit on Challenges in Recruitment, Retention, and Career Development in Geriatric Mental Health Research in late 2007. Major identified challenges included attracting and developing early-career investigators into the field of GMH research; a shortfall of geriatric clinical providers and researchers; a disproportionate lack of minority researchers; inadequate mentoring and career development resources; and the loss of promising researchers during the vulnerable period of transition from research training to independent research funding. The field of GMH research has been at the forefront of developing successful programs that address these issues while spanning the spectrum of research career development. These programs serve as a model for other fields and disciplines. Core elements of these multicomponent programs include summer internships to foster early interest in GMH research (Summer Training on Aging Research Topics-Mental Health Program), research sponsorships aimed at recruitment into the field of geriatric psychiatry (Stepping Stones), research training institutes for early career development (Summer Research Institute in Geriatric Psychiatry), mentored intensive programs on developing and obtaining a first research grant (Advanced Research Institute in Geriatric Psychiatry), targeted development of minority researchers (Institute for Research Minority Training on Mental Health and Aging), and a Web-based clearinghouse of mentoring seminars and resources (MedEdMentoring.org). This report discusses implications of and principles for disseminating these programs, including examples of replications in fields besides GMH research.

The need for adequate mental health services for older adults is an increasingly urgent issue as the life expectancy of Americans continues to extend; yet there are unresolved questions regarding the public's perception of service needs. The Group for the Advancement of Psychiatry collaborated with advice columnist Jeannie Phillips of "Dear Abby" to invite public feedback on mental health services for the elderly. Feedback was invited on access to services as well as perceived need for improvement in the quality or quantity of those services. The effort resulted in 800 responses that identified three primary issues: problems in accessing care, inadequate detection of mental health conditions by general practitioners, and a need for more psychotherapy services. It is hoped that this Open Forum will stimulate discussion throughout the country for the benefit of older persons with mental health needs as the country grapples with changes to come after the passage of health care reform.

Institutions such as the NIA and the Alzheimer's Association consider poor representation of ethnic minorities in AD clinical trials a major obstacle in Alzheimer's research. Although literature on this issue is extensive, the information is mostly anecdotal and experiential; a dearth of information scientifically obtained from well-designed studies exists. We present the early results of a qualitative study designed to understand the African American decision-making process to participate in AD clinical trials. Seven focus groups with 4-7 participants each were conducted. Participants were African Americans ≥ 55 years of age recruited from churches, community associations, and word-of-mouth referrals. Participants were caregivers of AD patients. All focus groups were facilitated by the same person, conducted in a location convenient for participants. Proper compensation was provided. Focus groups were semi-structured, lasting for an hour. Data was recorded by a stenographer; all sessions were tape-recorded and transcribed. Data was analyzed using qualitative computer-based analysis programs designed to extract common themes from the focus groups. 83% of the participants were female; 17% male 48% were between the ages of 55-64; 26% were 65-74; 22% were 75-84; 4% were older than 85. 22% of participants completed less than high school; 30% completed high school; 35% completed some college; 4% have a college degree only; 9% have an advanced degree. 61% have household incomes of less than $20,000 a year; 22% has household income between 20,000- 39,000; 17% 40,000 and above. 13% were employed; 87% were retired. 44% married, 39% widowed, 13% divorced. An analysis of the decision making process highlighted the presence of specific key parameters: #1 Trust of the provider making the request #2 Input of the primary medical doctor (if not the one making the request) #3 Distrust to participate in preliminary drug development #4 Required level of involvement and risk Other factors will also be discussed. Against available anecdotal information, our data suggest the presence of key elements related to the clinical trial participation decision-making process. Addressing such issues in well-designed interventions could be the answer to overcome the lack of diversity in clinical trials that challenges researchers.

Background/Aims: The recruitment of culturally diverse subject populations into research studies, particularly African-Americans (AA), has been the focus of intense interest by many groups. Methods: In this paper, we present the methodology utilized to create a predominantly AA cohort for the longitudinal study of risk factors in Alzheimer’s disease (AD). The underlying strategy was that of identifying geographically diverse clinical venues within South Carolina (SC) where large numbers of AA patients already come to seek medical care. Results: This strategy was successful, although recruitment rates for AA subjects (43.4%) still fell below those for white subjects (70.3%; p = 0.0025). Subject characteristics of AA subjects that chose to enroll were not substantially different from those that declined to participate. The demographic characteristics of this cohort were largely similar to those of the SC Alzheimer Disease Registry, a population-based database. The problems of standardization of subject recruitment and assessment across diverse clinical venues are also addressed. Conclusion: The utilization of geographically diverse sites for research recruitment where minorities already receive medical care is one practical solution to the problem of minority participation in research. Multi-site recruitment to improve minority recruitment can be accomplished with acceptable standardization and inter-rater reliability.

We are witnessing a demographic explosion of diversity in our elderly population. It is anticipated by 2050 that the proportion of African American and Hispanic elders in the United States will approximately double and triple, respectively. 1 US Census Bureau. Available at: http://www.census.gov/ Google Scholar Racial and ethnic minority elders are also confronted with health disparities resulting in subsequent poorer health than their white counterparts. It is therefore critical to increase our awareness and knowledge of health issues related to racial and ethnic minorities. The lead articles for this theme issue—Ethnicity and Geriatric Psychiatry—offer exciting new data on mental health disorders among older ethnic minorities and older African Americans in particular. 2 Neighbors HW Woodward AT Bullard KM et al. Mental health service use among older African Americans: the National Survey of American Life. Am J Geriatr Psychiatry. 2008; 16: 948-956 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar , 3 Chatters LM Bullard KM Taylor RJ et al. Religious participation and DSM-IV disorders among older African Americans: findings from the National Survey of American Life. Am J Geriatr Psychiatry. 2008; 16: 957-965 Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar , 4 Bankole A Cohen CI Vahia I et al. Symptomatic remission in a multi-racial urban population of older adults with schizophrenia. Am J Geriatr Psychiatry. 2008; 16: 966-973 Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar

Objective: Despite numerous clinical trials, it is unknown whether ethnicity affects treatment response to cognitive enhancers in Alzheimer's disease (AD). There is convincing evidence of ethnic and genetic variability in drug metabolism. This article reviews the available data on ethnicity in clinical trials for AD to answer two questions: (1) what are the challenges to diagnose and treat AD across different ethnic groups, and (2) are there differences in response to pharmacologic interventions for AD across these different ethnic groups? Method: Available data from Alzheimer's Disease Cooperative Study (ADCS) randomized controlled clinical trials and from randomized controlled industry-sponsored trials for four cognitive enhancers (donepezil, galantamine, rivastigmine and sabeluzole) were pooled to assess the numbers of non-Caucasian participants. Results: The participation of ethnic minority subjects in clinical trials for AD was dependent on the funding source, although Caucasian participants were over-represented and non-Caucasian participants were under-represented in the clinical trials. Because of the low participation rate of ethnic minorities, there were insufficient data to assess any differences in treatment outcome among different ethnic groups. Strategies to improve diversity in clinical trials are discussed. Conclusion: Greater participation of ethnically diverse participants in clinical trials for AD would generate additional information on possible differences in metabolism, treatment response, adverse events to therapeutic agents, and could foster the investigation of genetic variability among ethnic groups.

The Specific Aim of the proposal was to develop an administrative structure that will facilitate the development of AD research across the state of SC by providing key services such as (but not limited to) seeking funding research opportunities, financial tracking, regulatory management, central recruitment, training for investigators and coordinators, data collection, data storing, and data processing to researchers across the state.

To test the hypothesis that older, dementing African Americans and Caucasians differ in their patterns of deterioration in the domains of language and memory. Sixty–nine initial participants (African American n=55, Caucasian n=14) from a multi–site, 5–year trial investigating the expression and progression of Alzheimer's Disease (AD) in South Carolina, USA were evaluated. Subjects were diagnosed either as asymptomatic, suffering from Mild Cognitive Impairment (MCI), or Probable AD. All participants underwent extensive individual diagnostic and psychometric evaluation. In the present study, we examined the differences in the pattern of memory and language performance at comparable levels of cognitive function as defined by Mini Mental State Examination (MMSE) scores for African Americans and Caucasians. There was no statistically significant difference in age or educational attainment between African American or Caucasian groups. Using a regression model, African Americans' performance declined significantly more slowly than performance of Caucasians' on the CERAD–Word List (WL) Recall (p = .02). African Americans with MMSE scores at or below 13 recalled no items on WL recall. However, Caucasians’ WL recall scores were uniformly zero when MMSE scores were at or below 23. Using a second regression model, performance of African Americans on a measure of language (Boston Naming Test [BNT]), seemed to decline more quickly than performance of Caucasians (p = .003). Results should be interpreted cautiously due to small sample sizes. Analyses suggest that patterns of cognitive deterioration on measures of memory and language are different for African Americans and Caucasians at comparable levels of general cognition. These findings would suggest that different cognitive realms decline at different rates for African Americans and Caucasians. Reasons for these findings are unclear and possible causal factors will be discussed.

Alzheimer's disease is a devastating neurological disorder characterized by cognitive deficits, functional impairment, and often troublesome behavioral symptoms. Unfortunately, Alzheimer's disease can be difficult to diagnose at early and even moderate stages of the disease. This article outlines simple, efficient strategies for identifying patients with potential dementia. The discussion focuses on the key components of a comprehensive assessment plan, which typically involves taking the patient's history, as well as conducting cognitive testing, laboratory testing, neurologic examination, and neuroimaging to evaluate patients for Alzheimer's disease. Finally, opportunities for the improvement of care are discussed, with an emphasis on overcoming barriers to diagnosis such as time limitations and reimbursement issues.

Alzheimer's disease is a progressive, debilitating form of dementia affecting more than 18 million people worldwide. Without a cure, many patients and their families must turn to long-term care institutions during the later stages of the disease. Our current treatments only delay progression and help control behavioral symptoms. In recent years, research within this field has expanded to include many clinical trials on potential drug therapies. However, despite the numerous studies, the enigma of this disease remains. It is difficult yet necessary, to stay abreast of emerging information that may warrant changes in current therapy. Rationale for combination therapy becomes evident as we review the multiple neurochemical pathways common to the disease. This paper will review available information on Alzheimer's disease pharmacotherapy, and evaluate data on the use of combination drug therapy. Individual efficacy, possible synergistic effects, and the safety of combination therapy will also be addressed.