About half of older U.S. adults receive a diagnosis of Alzheimer’s disease or related dementia shortly before their death — a number that has spiked by more than 34% in two decades, according to a new Medicare billing study. More awareness and changes in Medicare billing protocols may account for the increase, investigators say.
The researchers, from the University of Michigan, analyzed fee-for-service Medicare billings from 3.5 million patients aged 67 and older between 2004 and 2017. Approximately 35% of billing claims from 2004 included at least one mention of dementia within two years of death. By 2017, more than 47% claims did so. These increases were more evident in inpatient, hospice and home health settings, the researchers reported.
Awareness up, billing altered
Rather than reflecting more dementia in the general population, the increase most likely is a result of increased awareness among clinicians, patients and caregivers, and a spike in recorded diagnoses from 2011 to 2013, the investigators wrote. Those years saw a substantial increase in the number of diagnoses Medicare allowed on claims.
Taken as a whole, the results suggest that underdiagnosis of dementia is declining, according to lead author Matthew A. Davis, Ph.D., MPH.
“That said, identification within the last two years of life is a minor improvement considering the disease course for ADRD spans 10 years,” he and his colleagues wrote.
No drop in invasive procedures
Intensity of end-of-life care has declined on most measures, but not on some key invasive procedures, the investigation also revealed. There has been a notable decrease in the use of feeding tubes in nursing homes, for example. In the general population, there has been an increase in hospice use and lower likelihood of dying in the hospital despite the persistence of frequent transfers, Davis reported.
But there has been no corresponding decrease in the use of invasive life-prolonging procedures such as mechanical ventilation and dialysis, the authors added.
“One potential benefit of greater disease identification in late-stage disease is the opportunity to engage in end-of-life care discussions,” wrote Davis. But “the present results do not support an association between higher ADRD diagnosis frequency and less aggressive end-of-life care.”
Full findings were published in JAMA Health Forum.