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Alzheimer’s and Dementia

Apr 26
Headshot of Julie Zissimopoulos with name and title

Associate Professor Julie Zissimopoulos: the impact and economics of Alzheimer’s

By Alzheimer's and Dementia, Lifespan Health, Podcast, Policy

Julie Zissimopoulos is an associate professor in the USC Price School of Public Policy and the co-director of the Aging and Cognition Initiative at the USC Schaeffer Center for Health Policy and Economics, where she’s also a senior fellow and the director of two NIA-funded centers that support innovative social science research on dementia.

She recently spoke to us about her research using economic insights to better understand the impact of Alzheimer’s disease on individuals, families, caregivers, and society.

On the demographics of Alzheimer’s disease

“People are living longer than ever. So, for example, today about 50 million Americans are aged 65 and older. It was about half that in 1950. And by 2050, the US census projects about 20% of the population will be 65 and older. And age is one of the foremost risk factors for Alzheimer’s and other dementias. So what does this mean for our future? Well, it means that without new treatments or innovations or ways to prevent or delay Alzheimer’s and dementia, the number of persons living with this disease will be about 12 million by 2050.

The risk of Alzheimer’s is really a risk at older ages and it rises dramatically with age. So for individuals 65 to 79, about 7% of them will have dementia. But in your eighties, the risk of dementia is about 20% prevalence. And by 85 and older, if you live that long, about 40% of those persons will have Alzheimer’s. It’s also much higher for women than men. And that difference is not explained just by the longer lifespans of women compared to men. It’s also about one and a half to two times higher for Blacks, Hispanics, American Indians, and indigenous Americans compared to whites. And we know a little bit about what explains some of the differences by race. Some of its explained by education and prevalence of chronic conditions that are associated with a higher risk of dementia, like hypertension and diabetes, but it does not explain it all.”

On cognitive assessments at wellness visits

“We collected data from a nationally representative sample of older Americans to understand better their use of annual wellness visits and the cognitive assessments. And what we found that was only about a quarter of them who received an annual visit also reported receiving a cognitive assessment. And this was higher for beneficiaries who were in Medicare Advantage-type plans versus those who were in the traditional Medicare plans. And this might have an important indication that these traditional benefit plans, the Medicare benefit plans, where there’s direct service-related payment for a set of bundled services, like at the annual wellness visit, may not be a very efficient way to increase our cognitive assessments. We also, I think, have some opportunities to improve our policy around cognitive assessments. Right now there’s no guidance about what constitutes a cognitive assessment or how it should be performed. So a clinician can use a structured tool, which we have many of, or they might just ask the beneficiary, the patient if they’re concerned about their memory. And so all of these factors may affect whether we are actually providing good early detection or not.”

On the costs of Alzheimer’s

“Along with the incredible health toll that Alzheimer’s and dementia takes on a person and their families, it also takes an incredible, tremendous financial on the person who’s living with dementia and their family. Alzheimer’s disease leads to cognitive decline slowly destroying brain functioning. It also leads many to behavioral and psychiatric disorders and declines inability to self-care, functional status. And all of this is extremely, extremely costly. So we estimated the costs for all the persons with Alzheimer’s disease, other medical care costs in long-term care costs, and it’s about $200 billion. But that’s only a partial portion of the costs. So as I mentioned persons with dementia need a lot of care and much of this care is provided by family members, unpaid care. And if you value the hours of family members caregiving, that’s about a hundred billion dollars So we’re talking about over $300 billion in costs of care for dementia. And this is more than the cost of cancer and heart disease combined.

There is a growing literature… looking at what are these impacts on the unpaid care provided by family members and other caregivers. And there’s very consistent evidence that there is negative health effects, particularly on mental health. Caregiving for a person with dementia, particularly as the disease progresses from mild symptoms to severe is a very stressful type of caregiving. There’s a very long arm of financial impacts. For spouses, wealth is consumed to pay for long-term care. So care in a facility such as a nursing home can cost anywhere between $50-100 thousand a year. And most families don’t qualify for Medicare that reimburses for the cost of long-term care. And for adult children who are caregivers, there are impacts on their work productivity, their ability to maintain work in the labor force on their income. We don’t have, as a nation, national family leave policies to support and pay for time away from work for caring for older family members with dementia or other conditions.”

On the need for policy changes

“I think one important policy change is we need solutions to support family caregivers in the workplace, compensation programs. But this isn’t going to be enough. Demographic trends suggest that family caregiving as the main source of care is likely not sustainable. People are having fewer children and they are more Americans with dementia. So we really need an insurance system to cover long-term care. The current system does not function well who, who take it up, tend to only be those at high risk with very high healthcare costs. So we need to be a little innovative here, maybe consider a voluntary auto-enrollment in long-term care insurance with an opt-out much like what has worked well in the retirement savings market. Medicare could also help; we had a new benefit of Part D that covers drug expenditures and protects against very high out-of-pocket spending for those beneficiaries with high drug expenditures. This was very successful. Medicare could do something similar for long-term care, but it will be very costly. So we will need to figure out who will pay, how we will finance this and, and, and who is going to bear the costs of this. Will it be the younger generation through taxes on, say, health insurance premiums? If so, how are we going to make sure that they don’t bear the full burden?”

On future research goals

“I’m very interested in continuing to try to understand how drugs for our chronic conditions are affecting our risk of Alzheimer’s. Looking at anti-diabetics right now, and some of those drugs that are potentially increasing the risk of Alzheimer’s and dementia. I’ve been working on understanding and reducing barriers to early detection, how we might improve that and have some real impact there. And then there are many policy changes that are happening to Medicare, new benefits and Medicare advantage and these could all impact the care and quality of life for persons living with dementia. And it’s important for us to understand what care systems best serve the needs of those individuals, protect against financial impacts for them and their families.”

On the importance of social science research

“…Social science has a lot to offer in terms of identifying opportunities to reduce risk, reduce disparities in risk and improve quality of life and care, and really reduce financial burden. And at the USC Schaeffer Center for Health Policy and Economics and in collaboration with the school of gerontology, we have two NIH-funded centers that support grant awards and mentorship opportunities for social science scholars who are interested in this area of research. Through efforts like this and growing this area of research, I think we can make an immediate impact while we hopefully wait for clinical development of that drug that everyone is hoping for.”

Feb 25
Headshot of Hussein Yassine with name and faculty title

Dr. Hussein Yassine: Uncovering links between nutrition, genes, and risk for Alzheimer’s disease

By Alzheimer's and Dementia, Lifespan Health, Podcast, Research

Dr. Hussein Yassine is a professor of medicine at the Keck School of Medicine at USC and is uncovering links between nutrition, genes, and risk for Alzheimer’s disease. He spoke to us about his research on APOE4, omega-3s and inflammation in the brain.

On APOE4 and Alzheimer’s risk

So APOE is a gene on chromosome 19. It exists in the population in three different forms. The two form, not very common, the three form, the most common and the four form, which makes about 20% of the population. The four form, if you get one copy from your parents, your chances of getting Alzheimer’s disease increased two to four times. If you inherit two copies, meaning you get one copy from mom and one copy from dad,  your chances of getting Alzheimer’s, or the odds ratio, goes to 12 times, meaning an APOE4 E4 homozygote, uh, 50% of those homozygotes by the age of 80 will have Alzheimer’s disease.

On the work of his lab

My lab is working to understand whether omega-3s can slow down cognitive decline in people at high risk of Alzheimer’s disease, based on APOE4. We are working on three different fronts. One, we have basic science models where we study the brains of APOE4 targeted replacement mice. We use brain imaging to study labeled DHA brain uptake in the human brain, and we do clinical trials where we give people omega-3 supplementation and look at outcomes.

On omega-3 supplements versus dietary interventions

At this point in time, we do not have high quality evidence to suggest that supplements make a difference. But we know from landmark observational cohorts, for example, the Framingham in the US, the Triple C in France, the Rotterdam in the Netherlands, and many others that people who consume at least one serving of fatty fish per week have lower risk of developing Alzheimer’s disease. In contrast trials that have involved omega-3 supplements have not panned out. And as we discussed, omega-3 supplements might be too late to be given to patients with neurodegeneration because they may not reverse neuronal death. Giving omega-3s to the general population may prove to be very difficult because the majority of people do not develop Alzheimer’s. So we need more research before we can recommend supplements. In addition, we don’t know exactly what kind of supplements we should be providing, the exact dose, the composition that duration. More research is needed to figure out those questions.

On what can people do to reduce Alzheimer’s disease risk

I think timing is key. I think if you know that you are at increased risk based on family history or APOE4 genotype  nutritional and lifestyle interventions during middle age will provide you likely the most benefit. Our research and others suggest that between the ages of 45 and 65, those at risk individuals should be on certain lifestyle modifications, whether it is at least one serving of fatty fish per week, or some good exercise regimen. We’re not talking about marathon running, maybe three times a week, 15 minutes per day is good enough. Lifestyle modifications, no smoking, reduced consumption of simple sugars to avoid complications of diabetes and obesity, increased intake of green leafy vegetables, which are enriched in polyphenols and antioxidants, good sleep, listening to music, certain forms of meditation, or in some individuals praying. And, uh, all of these factors, we know that have positive effect on mitigating or decreasing the chances of getting Alzheimer’s.

One additional factor that I did not discuss is hypertension or blood pressure control.  Blood pressure is known as a silent killer, because people have blood pressure, but they don’t know that they do so. Blood pressure control, diabetes control, cholesterol control in middle age together with these lifestyle changes can really pay dividends decades later. Once people start having symptoms and we’re talking now 60 to 80, they often come to us and they’re talking to us about omega-3 intake, about all these changes. And unfortunately at this time, the interventions are not very effective.

On the most important points  Dr. Yassine hopes people understand from  his research?

The biggest takeaway is that there is a life-course risk of Alzheimer’s disease risk in APOE4 carriers that starts shortly after birth. But mainly it takes decades before symptoms start. We know from imaging studies, between the ages of 20 all the way to 60, that the APOE4 brain is compensating to maintain cognition. Once this compensation fails, APOE4 carrier brains starts deteriorating, and you see signs of neurodegeneration and Alzheimer’s dementia. Our research emphasizes the importance of a healthy lifestyle, which includes sufficient omega-3 consumption, defined as at least one serving of fatty fish per week, lifestyle factors such as exercise, sleeping, music, meditation, family connections, combating depression, and social isolation, and social isolation is a problem now with COVID. And in addition to that, not smoking and reducing the amount of simple sugars consumed to reduce diabetes and cardiometabolic risk. Those interventions, we all know that they are critical, but our research suggests that there’s a critical time to do these interventions during middle age, to prevent the progression to Alzheimer’s at the age of 65 to 75. Once patients develop this disease, those interventions become less effective. So this is the greatest takeaway from the research we are doing.

On his message to young people

So my message to young people is that if you have a family history of Alzheimer’s disease, or that you know that you are an E4 carrier, plan in advance. Learn about the risks of Alzheimer’s disease, learn about the risks of carrying the APOE4 genotype and get informed, because we have cutting-edge research to help you out in preventing the risks of this disease early on.

On the importance of Alzheimer’s research

Up to 25% of individuals carry APOE4. So in a room of a hundred people, 25 people will have one copy of APOE4, that’s enormous. And they make the bulk, up to 50%, of patients with Alzheimer’s. We have so many APOE4 carriers in the community, and I think more research in this area is very important to the future of mitigating or changing the risk of Alzheimer’s disease. We should start early and we should try the best we can to prevent this disease because we know once it happens, it’s very difficult to treat.

On how to reach Dr. Yassine

If anybody listening to the podcast has family members with Alzheimer’s disease, they are concerned about being an APOE4 carrier and would require more advice or perhaps participate in any of our trials. Please feel free to email me. My email is hyassine@usc.edu, and you can look me up at the USC directory website and I’m happy to help.

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