Abstract
Objectives
This study aimed to estimate the costs of formal and informal care of patients with Alzheimer's disease, to compare care costs across European countries and identify potential differences in cost patterns between countries and regions.
Setting
The ICTUS study is a prospective, naturalistic observational study conducted in specialised memory clinics in 12 European countries. In total, 1385 patients diagnosed with Alzheimer's disease were enrolled at baseline. All subjects had a reliable informant (primary caregiver) and informed consent was obtained from patients or their primary caregiver.
Main outcome measures
Resource utilization data was captured with the RUD Lite (Resource Utilization in Dementia) instrument and caregiver burden with the Zarit Burden Interview (ZBI). Patient disease severity was measured with the Mini-Mental State Examination (MMSE), Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-cog), Katz' index (PADL), Instrumental activities of daily living (IADL) scale and Neuropsychiatric inventory (NPI).
Results
The mean annual cost of care per patient was estimated to €7,820 (95% CI: €7,194–€8,446), whereof 54% were costs of informal care, 16% direct medical costs and 30% community care costs. There were substantial differences in total resource utilization and also in the balance between formal and informal care between Northern, Western and Southern Europe. PADL scores were strongly associated with formal care costs while IADL scores correlated strongly with informal care costs.
Conclusions
Costs of Alzheimer's Disease are high across European countries. Activities of daily living is an important determinant of care costs. Formal care service use is lower and informal care higher in Southern Europe compared to Western and Northern Europe. Differences in resource utilization patterns are important to consider in international studies of dementia care costs as well as in economic evaluations of new treatments for dementia.
Key words: Alzheimer, economics, cost of illness
Introduction
The economic burden of dementia is receiving increasing attention as demographic changes lead to dramatic worldwide increases in dementia prevalence (1). The total worldwide costs of dementia have been estimated to 315 billion US$ in 2005, of which 38% in Europe (2).
Novel methods for diagnosing and treating dementia disorders need to be evaluated from an economic perspective to make sure health care resources are efficiently allocated. The starting point for any economic analysis is a description of how resource utilization and costs of care develop with disease progression. Previous analyses have focussed primarily on Mini-Mental State Examination (MMSE) scores as an indicator of cognitive function and disease severity, and have found strong correlations between MMSE scores and costs (3). However, the utility of the MMSE scale in assessing changes over time has been challenged (4), and the “floor effect” of the scale makes it less applicable in severe dementia. There is a need for data linking costs to disease progression described by factors that are more closely linked to disease burden and care needs, including activities of daily living (ADL) and behavioural disturbances, which are known important drivers of resource use and costs in dementia. This would enable improved precision and accuracy in the decision analytic models used for economic evaluation of health care interventions, and thereby provide decision makers with better evidence.
A recent review of the cost of illness literature on dementia in Europe identified 16 studies with patient-level data on costs of care (5). Estimates ranged between €6,614 and €64,426 per patient and year depending on country and study methodology. Costs for special accommodation and informal care (i.e. care provided by family or friends) are commonly the most important components but highly variable across studies due to variation in the selection of subjects (many studies only include community dwelling subjects) and valuation of informal care (there is no consensus on how to value this non-marketed good).
The literature on the cost of illness of dementia is heterogeneous; while all cost-of-illness studies indicate very high global costs of care, methodological differences between studies in how resources are measured and valued prohibit meaningful comparison between studies and across countries (5, 6, 7). It is understood that dementia care delivery exhibits large variations both across and within countries. This has consequences for efforts to conduct economic evaluation alongside multi-center clinical trials. As an alternative and a complement to model-based economic evaluation, direct assessment of costs and effects in the context of a prospective, randomized controlled trial has obvious advantages in internal validity and methodological consistency with the evaluation of efficacy and safety. However, the heterogeneity in resource use and costs across countries and regions poses challenges for interpreting pooled data from a multi-center trial.
The ICTUS study is a large, multi-national observational study in which economic endpoints are assessed in a consistent fashion across countries. This study provides a novel opportunity to study international differences in resource utilisation and care costs, and the study will provide important background information required to assess the cost-effectiveness of novel therapeutic options in Alzheimer's disease.
The objective of this study was to estimate the costs of formal and informal care of patients with Alzheimer's disease, to compare care costs across European countries and identify potential differences in cost patterns between countries and regions.
Materials and methods
Study design
The design of the ICTUS study has been described in detail elsewhere (8). It was a prospective observational study over a 2-year period with 6-monthly patient reviews.
Subjects were recruited from 29 memory clinics in 12 European countries. All clinics were members of the European Alzheimer's Disease Consortium (EADC).
Study subjects
Consecutive patients with a probable diagnosis of Alzheimer's disease according to the NINCDS-ADRDA criteria (9) and of mild to moderate severity (i.e. a Mini Mental State Examination, MMSE (10) score between 10 and 26, inclusive) were recruited into the study. Further inclusion criteria were: the patient was living independently at home with support of an informal caregiver who accepted participation in the study and the patient had no pathology leading to a prognosis of less than 2 years' life expectancy. Patients were excluded if: they were suffering from severe dementia (MMSE < 10), they were living in nursing home at entry, they had a pathology leading to a prognosis of less than 2 years' life expectancy, their caregiver could not be identified or they were participating in a randomized controlled trial.
Assessments
Data was collected at baseline through questionnaires to the primary caregivers (i.e. informal caregiver according to inclusion criteria; usually a family member or friend of the patient) and by review of medical records. The Resource Utilisation in Dementia (RUD) Lite instrument was employed to record the use of health care resources, community care services and the amount of informal care time spent on personal and instrumental ADL, and supervision (11, 12). The RUD Lite instrument captures the utilization of a range of community care resources, special accommodation, inpatient care and informal care (i.e. time spent by the primary non-professional caregiver on personal and instrumental ADL tasks, and supervision). The RUD questions have been validated in several studies (13, 26). Caregivers were asked to recall the resources used during the last month. They could not report more than 24 hours per day spent on each informal care task, although they could sum to more than 24 hours. Cognitive function was assessed with the Alzheimer's Disease Assessment Scale- Cognitive subscale (ADAS-Cog) (14) and the Mini-Mental State Examination (MMSE) (10). Personal and instrumental ADL capabilities were assessed with the Katz´ index (PADL) (15) and the Instrumental activities of daily living (IADL) scale [16]. For both ADL scales, a higher score indicates a higher independence. The Neuropsychiatric inventory (NPI) (17) was used to measure behavioural symptoms and the Zarit Burden Interview (ZBI)(18) for caregiver burden.
Cost calculations
Costs were estimated by multiplying quantities of resources used with the unit cost of each resource. In absence of unit cost data from all participating countries, a common price vector collected from Swedish sources was used for all. This price vector was then adjusted for differences in price levels across countries using comparative price levels reported from Eurostat (19)and converted into Euros (2006), see table 2. Informal care was priced at €3 per hour reflecting the opportunity cost of non-working time (20). The only form of accepted special accommodation at baseline was an intermediate non-dementia specific residential care facility, where the staff resources are zero or very low. The cost for this form of accommodation was assumed at €64 per day (3).
Table 2.
Resource utilisation; number of contacts per month (highest number in parenthesis)
| Nurse | Home help | Home-delivered meal | Day care | Transport | Other service | Days in hospital | |
|---|---|---|---|---|---|---|---|
| Belgium | 0.07 (2) | 2.13 (30) | 1.61 (30) | 1.43 (30) | 0.2 (9) | 0.02 (1) | 0 (0) |
| France | 4.58 (93) | 4.23 (80) | 0.96 (30) | 0.02 (5) | 0.07 (8) | 0.43 (30) | 0.26 (20) |
| Germany, Switzerland* | 3.42 (60) | 1.20 (20) | 1.30 (30) | 1.17 (60) | 0.59 (40) | 0.58 (21) | 0.04 (3) |
| United Kingdom | 0.99 (60) | 0.90 (56) | 0.81 (30) | 0.57 (20) | 0.81 (40) | 0.05 (2) | 0.26 (21) |
| Greece | 0 (0) | 0.50 (30) | 0 (0) | 0 (0) | 0 (0) | 0 (0) | 0.25 (10) |
| The Netherlands | 0.64 (30) | 3.28 (60) | 0.63 (30) | 1.58 (25) | 0.98 (24) | 0.17 (12) | 0.03 (3) |
| Italia | 0.08 (4) | 1.77 (30) | 0 (0) | 0.03 (4) | 0 (0) | 0.06 (5) | 0.04 (4) |
| Romania | 0.20 (10) | 0.01 (1) | 0 (0) | 0 (0) | 0.06 (4) | 0 (0) | 5.49 (31) |
| Sweden, Denmark* | 1.01 (30) | 3.89 (90) | 0.91 (30) | 0.54 (12) | 0.28 (12) | 0.37 (30) | 0.02 (2) |
| Spain | 0.21 (30) | 2.00 (30) | 0 (0) | 0.58 (20) | 0.24 (22) | 0.14 (20) | 0.09 (10) |
| All | 1.61 (93) | 2.38 (90) | 0.57 (30) | 0.45 (60) | 0.26 (40) | 0.22 (30) | 0.45 (31) |
| Unit cost** | 41€ | 25€ | 9€ | 45€ | 19€ | 11€ | 333-538€ |
Data have been pooled for Germany/Switzerland and Sweden/Denmark due to low sample size;
Per visit/day as described in Jönsson et al. (3)
Statistical analysis
Pair-wise correlations between disease indicators, caregiver burden and time spent on informal care were estimated to examine linear relationships. Cluster analysis with k-means methods (21) were used to explore differences and similarities in resource use across countries. A generalized linear model (GLM) with a log link function and assuming gamma distributed residuals was estimated to explore what factors were associated with higher costs of care. This approach has been proposed in analysis of cost data due to the non-normality of cost distributions (27).
Results
A total of 1,381 subjects were included at baseline, and complete costing data were available from 1,208 subjects (87%). The exclusion of 173 subjects was primarily due to non-completion of the RUD Lite instrument in a few Italian and Spanish study centers. There was very little missing data for other reasons.
Table 1 presents descriptive statistics for the included subjects by country. The majority (65%) of all patients were female. They were 76 years old on average and had an average MMSE score of 20 (range 10-26). Forty-three percent had very mild dementia (CDR 0.5) and 44% mild dementia (CDR 1) at baseline. Demographics and MMSE scores were very similar between countries. In Switzerland, with 32 included subjects, the share of patients with moderate dementia (CDR 2) was high (25%). About half of the patients were receiving treatment with a cholinesterase inhibitor at inclusion, with high variability between countries.
Table 1.
Description of study sample
| N (% male) | Mean age (range) | Share treated with cholinesterase inhibitor | Mean MMSE score (range) | Clinical Dementia Rating (CDR) | ||||
|---|---|---|---|---|---|---|---|---|
| 0.5 | 1 | 2 | 3 | |||||
| France | 310 (32%) | 77.5 (54-96) | 67.1% | 20.9 (11-26) | 39% | 48% | 13% | 1% |
| United Kingdom | 89 (42%) | 80.2 (56-96) | 48.3% | 21.2 (11-26) | 41% | 53% | 6% | 0% |
| Italia | 184 (28%) | 77.9 (55-93) | 35.3% | 20.1 (11-26) | 30% | 52% | 17% | 0% |
| Belgium | 56 (39%) | 74.1 (45-88) | 58.9% | 20.8 (11-26) | 50% | 34% | 14% | 2% |
| Switzerland | 32 (28%) | 77.1 (54-93) | 78.1% | 19.3 (11-26) | 41% | 34% | 25% | 0% |
| Spain | 292 (32%) | 77.2 (53-90) | 37.3% | 19.2 (10-26) | 50% | 38% | 12% | 0% |
| The Netherlands | 99 (44%) | 71.9 (52-93) | 27.3% | 20.5 (10-26) | 42% | 51% | 7% | 0% |
| Sweden | 41 (37%) | 73.5 (51-87) | 63.4% | 22.0 (11-26) | 49% | 39% | 12% | 0% |
| Germany | 49 (37%) | 73.4 (57-94) | 44.9% | 21.3 (11-26) | 24% | 63% | 12% | 0% |
| Denmark | 43 (44%) | 74.5 (52-88) | 9.3% | 22.4 (16-26) | 42% | 56% | 2% | 0% |
| Greece | 116 (41%) | 72.7 (54-91) | 38.8% | 21.2 (14-26) | 54% | 30% | 13% | 3% |
| Romania | 70 (46%) | 75.7 (40-92) | 75.7% | 20.1 (11-26) | 49% | 33% | 13% | 6% |
| All | 1381 (35%) | 76.3 (40-96) | 47.8% | 20.4 (10-26) | 43% | 44% | 12% | 1% |
Pair-wise correlation coefficients were calculated between indicators of cognitive function (MMSE, ADAS-Cog), ADL capabilities (PADL, IADL), behavioural symptoms (NPI) and caregiver burden (ZBI and time spent on personal ADL, instrumental ADL and supervision from RUD). All correlation coefficients were statistically significant at the 1% level and with the expected signs. The highest correlation was found between MMSE and ADAS-Cog scores (results not shown).
Figure 1 presents the average number of hours of informal care per day in each country, subdivided on personal ADL, instrumental ADL and supervision. There is substantial variability in the reported amount of informal care, ranging from about one hour per day with a predominance of instrumental ADL (Denmark) to six hours per day including also personal ADL and supervision (Italy). The mean (standard deviation) number of hours of personal ADL, instrumental ADL and supervision was 0.5 (1.5), 1.8 (2.8) and 1.7 (4.2), respectively. Thus, the highest variability was seen in the supervision component.
Figure 1.
Mean hours of informal care per day
Table 2 shows the formal resource utilization by country. Data was pooled for Sweden and Denmark, and also for Germany and Switzerland, due to a small sample size in each of these countries, geographical proximity and similar resource utilization patterns (no statistically significant differences in the use of any resource were found). In Romania, patients were commonly admitted to hospital for initial investigation for dementia, which explains the high number of days in hospital compared to other countries. On average, subjects had about four visits by nurse and home help per month and one day in day care or hospital per month, with high variability in resource utilisation.
The mean annual cost of care per patient was estimated to €7,820 (95% CI: €7,194 – €8,446), whereof 54% were costs of informal care, 16% direct medical costs and 30% community care costs.
In the cluster analysis, three groups of countries were identified based on similarities in 1) formal care costs and 2) informal care costs: Sweden, Denmark, UK, Belgium (“Northern Europe”), France, Germany, Switzerland, The Netherlands (“Western Europe”), and Italy, Spain, Greece, Romania (“Southern Europe”). Romania was considered an outlier due to the disproportionately high use of inpatient care and was excluded from the following comparisons.
In Table 3, costs of care are estimated and compared for the three regions. Costs of community care and medical care were highest in Western Europe and lowest in Southern Europe. Informal care costs were highest in Southern Europe and lowest in Northern Europe. Total annual costs were highest in Western Europe (€8,279) followed by Southern Europe (€7,049) and Northern Europe (€6,063), although confidence intervals were overlapping for all three regions.
Table 3.
Mean annual cost of care, €2006 (95% confidence interval)
| Northern Europe | Western Europe | Southern Europe | |
|---|---|---|---|
| Nurse | 352 (51-653) | 1716 (1192-2240) | 50 (0-105) |
| Home help | 710 (282-1139) | 1031 (811-1252) | 405 (262-549) |
| Home-delivered meals | 113 (44-182) | 102 (55-148) | 0 (0-0) |
| Daycare | 410 (152-667) | 259 (108-411) | 128 (49-208) |
| Transport | 141 (17-266) | 86 (32-140) | 40 (0-98) |
| Other service | 21 (0-56) | 51 (24-78) | 9 (0-20) |
| Accommodation | 286 (0-611) | 587 (271-904) | 43 (0-127) |
| Total, community care | 2043 (1290-2796) | 3800 (3024-4575) | 634 (442-826) |
| Medication | 562 (483-642) | 717 (662-772) | 406 (363-449) |
| Inpatient care | 651 (0-1706) | 710 (225-1194) | 450 (154-745) |
| Total, medical care | 1212 (159-2266) | 1431 (941-1920) | 907 (605-1209) |
| Personal ADL | 354 (184-523) | 318 (234-402) | 718 (539-897) |
| Instrumental ADL | 1594 (1161-2026) | 1365 (1194-1537) | 2212 (1922-2502) |
| Supervision | 887 (428-1347) | 1364 (1035-1693) | 2610 (2155-3064) |
| Total, informal care | 2846 (2003-3689) | 3057 (2589-3525) | 5500 (4818-6181) |
| Total cost | 6063 (4530-7597) | 8279 (7216-9341) | 7049 (6254-7843) |
Northern Europe: Sweden, Denmark, UK, Belgium; Western Europe: Germany, Switzerland, the Netherlands, France; Southern Europe: Spain, Italy, Greece
The GLM model showed that total care costs for individual subjects were associated with a range of disease severity indicators (table 4). High age and female gender were associated with high costs of care. Burden interview scores, which were highly correlated with NPI scores, were also positively related to costs of care. High PADL and IADL dependency and low ADAS-cog scores predicted high care costs. Costs were significantly higher in Western Europe than in Northern and Southern Europe, although the difference between the two latter regions was not significant.
Table 4.
Regression analysis of total annual costs of care (GLM model with log link)
| 95% CI for | |||||||
|---|---|---|---|---|---|---|---|
| Variable | e | Std. Err. | z | p | Lower | Upper | |
| Age | 0.021 | 1.021 | 0.006 | 3.69 | <.001 | 0.01 | 0.032 |
| Male | -0.574 | 0.563 | 0.114 | -5.04 | <.001 | -0.797 | -0.351 |
| ZBI | 0.006 | 1.006 | 0.003 | 2.01 | 0.044 | 0 | 0.011 |
| NPI | 0.004 | 1.004 | 0.003 | 1.42 | 0.155 | -0.001 | 0.009 |
| ADAS-cog | -0.023 | 0.977 | 0.008 | -2.92 | 0.004 | -0.039 | -0.008 |
| PADL | -0.311 | 0.733 | 0.051 | -6.13 | <.001 | -0.411 | -0.212 |
| IADL | -1.859 | 0.156 | 0.316 | -5.89 | <.001 | -2.477 | -1.24 |
| Southern Europe | -1.369 | 0.254 | 0.422 | -3.24 | 0.001 | -2.197 | -0.542 |
| Northern Europe | -2.829 | 0.059 | 0.797 | -3.55 | <.001 | -4.391 | -1.267 |
| Interaction terms | |||||||
| Southern Europe x PADL | 0.178 | 1.195 | 0.063 | 2.83 | 0.005 | 0.055 | 0.301 |
| Northern Europe x PADL | 0.304 | 1.355 | 0.129 | 2.36 | 0.018 | 0.052 | 0.556 |
| Southern Europe x ADAS-cog | 0.011 | 1.011 | 0.01 | 1.08 | 0.282 | -0.009 | 0.03 |
| Northern Europe x ADAS-cog | 0.046 | 1.047 | 0.013 | 3.66 | <.001 | 0.021 | 0.07 |
| Constant | 10.845 | 0.652 | 16.64 | <.001 | 9.568 | 12.122 | |
ZBI: Zarit Caregiver burden; NPI: neuropsychiatric inventory; ADAS cog: Alzheimer's Disease Assessment Scale – Cognitive subscale; ADL: activities of daily living; PADL: personal ADL function; IADL: instrumental ADL function;
We also examined potential differences between European regions in the association between costs and disease severity by including interaction terms in the regression model. Significant interaction effects were found between region and PADL scores, and between region and ADAS-Cog scores. PADL and ADAS-cog scores were stronger determinants of costs in Western Europe and weaker determinants in Northern Europe. No interaction effect was observed for IADL. These findings were also confirmed separately by ANOVA analysis on categorical variables (results not shown).
Figure 2, Figure 3, Figure 4 present average costs of care when subjects are stratified by region and also by PADL, IADL and MMSE scores, respectively. ADL dependency is clearly associated with higher costs of care. Formal care costs (especially community care) were more dependent on PADL dependency while differences in informal care costs were explained by both personal and IADL dependency. MMSE-related costs in Northern and Western Europe peaked in the middle.
Figure 2.
Annual cost of care (€), by region and PADL dependency
Figure 3.
Annual cost of care (€), by region and IADL dependency
Figure 4.
Annual cost of care (€), by region and MMSE score
Discussion
This study illustrates the large variations in resource utilization in Alzheimer's Disease across European countries, but also shows consistent relationships between costs and indicators of disease severity. PADL function is a strong predictor of both formal and informal care costs, while IADL function is associated primarily with informal care requirements. There was also a strong influence of informal care on the societal costs, particularly in the Southern Europe cluster, where the use of formal resources was the lowest, probably reflecting family and care traditions.
There were some unexpected findings in this study, including Northern Europe having the lowest societal costs and the lower costs in patients with moderately severe MMSE-related impairment. Both of these findings are probably explained by the selection of patients, i.e. not including patients in institutional care. As institutionalized care is more common in Northern Europe, and the most demanding and costly patients reside in these settings, the community dwelling patients in Northern Europe may be less demanding and costly than in other countries where patients stay at home for longer. Including all patients would probably lead to a relative increase in the costs of care in Northern Europe as compared to the rest of Europe. Similarly, by only including the more cognitively impaired patients if they still reside at home, this leads to a selection of relatively less demanding patients- perhaps even less demanding than patients with moderate cognitive impairment whom have not yet been considered for an institutionalized setting.
The great advantage of this study is that it is the first in which resource use and costs in Alzheimer's disease and its relation to different measures of disease severity and caregiver burden is studied across many European countries using the same set of instruments. By doing so, it is possible to study differences in care and resource utilization patterns in a more robust way. The variation in costs in different parts of Europe that is shown in this study reflects differences in care traditions and the availability of care resources. Differences in resource utilization patterns are important to consider in international studies of dementia care costs as well as in economic evaluations of new treatments for Alzheimer's disease.
Our findings also provide important input into the discussion on how to collect and analyze cost data within multinational randomized controlled trials. First of all, it is important to use a standardized instrument such as the RUD to assess resource utilization, as this will enhance the comparability between different centers and countries as well as between different studies. The RUD instrument is constructed to enable comparison between different countries and care systems and captures differences in actual resource use using a common terminology. Second, the pooling of cost data across several countries in a multinational study is only appropriate if the care patterns are the same (i.e. when pooling data we need to assume that they come from the same distribution of what we want to describe). We found differences in care patterns between three regions of Europe in our study. These clusters may serve as a starting point for pooling cost data from a multinational study including these countries.
Our results highlight the importance of informal care when estimating the costs of care in dementia from a societal perspective. This is true for all countries in our sample even though there were large differences between them. Informal care should also be a key target to show a treatment benefit in randomized controlled trial. In addition to having a large influence on the total care costs, informal care time should be sensitive to short term changes in patient dependence. Several previous studies have shown a treatment effect on informal care time (22, 23, 24) and RUD Lite should continue to be a standard secondary endpoint in randomized controlled trial in dementia.
Several recent studies have shown the relative importance of ADL dependence in explaining the variation in costs of care. Cognitive function is not as an important predictor and should foremost not be left alone to explain how the progression of Alzheimer's disease translates into increases in costs of care. This study also showed that IADL dependency primarily translates into higher informal care use in cross-section. Loss of IADL capabilities occurs early in the course of dementia while the patient is primarily dependent on help from their spouse, children or friends. However, the concept of instrumental ADLs is rather heterogeneous and further research is needed on how different types of instrumental ADLs contribute to resource use and costs. Furthermore, a longitudinal data set would be needed to derive conclusions on the causal relationship between disease progression and costs.
As noted in the introduction, results are expected to be sensitive to the valuation of informal care. In this study there is a risk of overestimating the value of informal care as caregivers could report a total informal care provision above 24 hours per day. On the other hand, the study did not capture any potential informal care provided by others than the primary caregiver, which makes us underestimate the total informal care provision. Another uncertainty in the cost estimates is the prices assumed for each resource. Country specific unit costs were not available which made us assume a common price vector adjusted for general price differences across countries. This approach should be valid as long as there are no important differences in relative prices between different resources across the countries, which should be a reasonable assumption for dementia in Europe.
Our cost estimates are comparable to previous cost of illness studies and differences are mainly explained by 1) the selection of patients, 2) the selection of recruitment centers, 3) the types of resources collected, and 4) the costing of resources (5). First and as noted above, this sample was a community dwelling sample of patients with mild to moderate severity. This should give lower cost estimates than studies including also more severely impaired patients living in institutionalized care settings. Second, we recruited patients primarily from memory clinics which should imply that our sample is representative to well-managed patients who are known to the health care system. The proportion of patients treated with cholinesterase inhibitors was relatively high in our sample as compared to estimates presented by (25), which is probably due to the recruitment of patients from memory clinics. Third, the RUD Lite which was used in this study includes the most important items of societal costs of care but excludes some items that would influence total costs e.g. outpatient care and concomitant medications. Fourth, unit costs reflecting the real opportunity cost of each resource are not available. As second best alternatives are used, they will vary across different studies and result in differences in cost estimates.
Conclusion
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–
costs of Alzheimer's disease are high across European countries
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formal resource use is the lowest in Southern Europe (Spain, Italy, Greece)
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total care costs (including informal care) is the lowest in Northern Europe (Sweden, Denmark, UK, Belgium) in a community dwelling sample
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PADL dependency is strongly related with formal care costs and informal care costs
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IADL dependency is strongly related to informal care costs
Footnotes
ON BEHALF OF THE ICTUS STUDY GROUP
ICTUS study group: B. Vellas (Toulouse), R.W. Jones (Bath), A. Burns (Manchester), R. Bullock (Swindon), A. Malick (Warwick), E. Salmon (Liege), G. Waldemar (Copenhagen), J.F. Dartigues (Bordeaux), F. Pasquier (Lille), J. Touchon (Montpellier), Ph. Robert (Nice), A.S. Rigaud (Paris), V. Camus (Tours), G. Stiens (Goettingen), L. Frölich (Mannheim), M. Tsolaki (Thessalonica), G. Frisoni (Brescia), G. Rodriguez (Genoa), A. Cherubini (Perugia), L. Spiru (Bucharest), M. Boada (Barcelona), A. Salva (Girona), E. Agéra-Morales (Cordoba), J.M. Ribera-Casado (Madrid), P.M. Lage (Pamplona), B. Winblad (Stockholm), D. Zekry (Geneva), P. Scheltens (Amsterdam), M. Olde-Rikkert (Nijmegen). Co-ordination: F. Cortes, C. Cantet, P.J. Ousset, C. Caillaud, E. Reynish
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