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Financial Presentation of Alzheimer Disease and Related Dementias

JAMA Intern Med. Published online November 30, 2020. doi:10.1001/jamainternmed.2020.6432 – “About 14.7% of American adults older than 70 years have Alzheimer disease and related dementias (ADRD), neurodegenerative conditions characterized by deteriorating cognitive function that impedes independence in daily activities through deficits in memory and other cognitive domains. Common ADRD symptoms, including memory problems and decreased attention and judgment, frequently impair personal financial management. Erratic bill payments, risky financial decisions, and susceptibility to financial fraud are widely recognized as early indicators of ADRD, though families and physicians often do not detect these behaviors until later in the course of the disease. Despite limited research regarding the full extent of dementia-related losses, there have been numerous lay press anecdotes of loved ones first learning of a patient’s decline through catastrophic financial events including foreclosure and asset depletion. Cognitively impaired older adults may be particularly vulnerable to financial exploitation, estimated to impact between 3% and 14% of older adults annually. Cognitive impairment often leads patients to overestimate their abilities and continue potentially inappropriate financial roles; 80% of primary financial decision-makers in couples maintain this role after cognitive decline consistent with dementia. Self-reported difficulties managing money and poor performance on financial capability tests predict increased risk of dementia. However, little is known about the overall prevalence and magnitude of ADRD-related financial errors. To date, ADRD studies have typically relied on survey assessment of financial abilities and outcomes in small samples. A 2017 meta-analysis summarizing the literature on financial capabilities and dementia included just 10 studies with a cumulative 1050 participants. The only study, to our knowledge, to examine the effects of ADRD on realized financial outcomes measured in administrative data for a large sample of Medicare beneficiaries found that beneficiaries were less likely to choose the lowest-cost prescription drug plan both before and after a formal diagnosis compared with people without ADRD.

If undiagnosed ADRD leads to costly financial errors, earlier diagnosis could be valuable even without effective treatments or cures. Most Americans routinely use credit products, generating real-time information on borrowing and repayment behavior. Early signs of impaired capabilities may manifest as missing payment on routine bills or inappropriate credit use. We linked administrative health care and demographic data from Medicare, the federal health insurance program for the elderly, to the Federal Reserve Bank of New York/Equifax Consumer Credit Panel (CCP/Equifax) to characterize the financial presentation of ADRD before and after diagnosis…”

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