Monetary costs of agitation in older adults with Alzheimer’s disease in the UK: prospective cohort study Stephen Morris, 1 Nishma Patel, 1 Gianluca Baio, 2 Lynsey Kelly, 3 Elanor Lewis-Holmes, 3 Rumana Z Omar, 2 Cornelius Katona, 3 Claudia Cooper, 3 Gill Livingston 3 To cite: Morris S, Patel N, Baio G, et al. Monetary costs of agitation in older adults with Alzheimer’s disease in the UK: prospective cohort study. BMJ Open 2015;5: e007382. doi:10.1136/ bmjopen-2014-007382 ▸ Prepublication history and additional material is available. To view please visit the journal (http://dx.doi.org/ 10.1136/bmjopen-2014- 007382). Received 5 December 2014 Revised 11 February 2015 Accepted 13 February 2015 For numbered affiliations see end of article. Correspondence to Professor Stephen Morris; [email protected]ABSTRACT Objective: While nearly half of all people with Alzheimer’s disease (AD) have agitation symptoms every month, little is known about the costs of agitation in AD. We calculated the monetary costs associated with agitation in older adults with AD in the UK from a National Health Service and personal social services perspective. Design: Prospective cohort study. Setting: London and the South East Region of the UK (LASER-AD study). Participants: 224 people with AD recruited between July 2002 and January 2003 and followed up for 54 months. Primary and secondary outcome measures: The primary outcome was health and social care costs, including accommodation costs and costs of contacts with health and social care services. Agitation was assessed using the Neuropsychiatric Inventory (NPI) agitation score. Results: After adjustment, health and social care costs varied significantly by agitation, from £29 000 over a 1 year period with no agitation symptoms (NPI agitation score=0) to £57 000 at the most severe levels of agitation (NPI agitation score=12; p=0.01). The mean excess cost associated with agitation per person with AD was £4091 a year, accounting for 12% of the health and social care costs of AD in our data, and equating to £2 billion a year across all people with AD in the UK. Conclusions: Agitation in people with AD represents a substantial monetary burden over and above the costs associated with cognitive impairment. INTRODUCTION The monetary cost of dementia is huge, with an estimated global burden in 2010 of US $604 billion incurred by health (16% of the total) and social care (42%) services and informal care (42%). 1 Around 70% of world- wide costs occur in North America and Western Europe 1 ; estimates for the UK show that the total monetary cost of dementia in 2014 was £26 billion. 2 Alzheimer’ s disease (AD) is the most common form of dementia, accounting for around 62% of cases. 2 Nearly half of all people with AD have agi- tation symptoms every month. 3 These are positively correlated with institutionalisation, 4 pharmacological treatment and use of medical services, 3 but there is no evidence on the costs of agitation in people with AD. 56 The aim of this paper is to calculate the monetary costs associated with agitation in AD. METHODS Participants We calculated National Health Service (NHS) and personal social services (PSS) costs associated with different levels of agita- tion using data from a naturalistic prospect- ive cohort study of people with AD, covering Strengths and limitations of this study ▪ This study used detailed, prospectively collected health and social care resource use data plus data on frequency and severity of agitation symp- toms over a 54-month period to calculate the costs of agitation in people with Alzheimer’s disease (AD). ▪ There is no previous evidence about the cost of agitation in AD, even though nearly half of all people with AD have agitation symptoms every month; this study calculated that the mean excess cost associated with agitation per person with AD was £4091 a year. ▪ A limitation of the study is that it is based on a relatively small data set of 224 people, recruited to be representative of those with AD between July 2002 and January 2003 and followed up to 54 months. ▪ We did not include the costs of informal care; these data were not collected and UK guidelines for undertaking economic evaluations recom- mend taking a health and social care perspective when measuring costs. Morris S, et al. BMJ Open 2015;5:e007382. doi:10.1136/bmjopen-2014-007382 1 Open Access Research on February 17, 2022 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007382 on 13 March 2015. Downloaded from on February 17, 2022 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007382 on 13 March 2015. Downloaded from on February 17, 2022 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007382 on 13 March 2015. Downloaded from on February 17, 2022 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007382 on 13 March 2015. Downloaded from on February 17, 2022 by guest. Protected by copyright. http://bmjopen.bmj.com/ BMJ Open: first published as 10.1136/bmjopen-2014-007382 on 13 March 2015. Downloaded from on February 17, 2022 by guest. 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Monetary costs of agitation in olderadults with Alzheimer’s disease in theUK: prospective cohort study
Stephen Morris,1 Nishma Patel,1 Gianluca Baio,2 Lynsey Kelly,3
Elanor Lewis-Holmes,3 Rumana Z Omar,2 Cornelius Katona,3 Claudia Cooper,3
Gill Livingston3
To cite: Morris S, Patel N,Baio G, et al. Monetary costsof agitation in older adultswith Alzheimer’s disease inthe UK: prospective cohortstudy. BMJ Open 2015;5:e007382. doi:10.1136/bmjopen-2014-007382
▸ Prepublication history andadditional material isavailable. To view please visitthe journal (http://dx.doi.org/10.1136/bmjopen-2014-007382).
Received 5 December 2014Revised 11 February 2015Accepted 13 February 2015
ABSTRACTObjective: While nearly half of all people withAlzheimer’s disease (AD) have agitation symptomsevery month, little is known about the costs of agitationin AD. We calculated the monetary costs associatedwith agitation in older adults with AD in the UK from aNational Health Service and personal social servicesperspective.Design: Prospective cohort study.Setting: London and the South East Region of the UK(LASER-AD study).Participants: 224 people with AD recruited betweenJuly 2002 and January 2003 and followed up for54 months.Primary and secondary outcome measures: Theprimary outcome was health and social care costs,including accommodation costs and costs of contactswith health and social care services. Agitation wasassessed using the Neuropsychiatric Inventory (NPI)agitation score.Results: After adjustment, health and social care costsvaried significantly by agitation, from £29 000 over a1 year period with no agitation symptoms (NPI agitationscore=0) to £57 000 at the most severe levels ofagitation (NPI agitation score=12; p=0.01). The meanexcess cost associated with agitation per person withAD was £4091 a year, accounting for 12% of the healthand social care costs of AD in our data, and equating to£2 billion a year across all people with AD in the UK.Conclusions: Agitation in people with AD represents asubstantial monetary burden over and above the costsassociated with cognitive impairment.
INTRODUCTIONThe monetary cost of dementia is huge, withan estimated global burden in 2010 of US$604 billion incurred by health (16% of thetotal) and social care (42%) services andinformal care (42%).1 Around 70% of world-wide costs occur in North America andWestern Europe1; estimates for the UK showthat the total monetary cost of dementia in2014 was £26 billion.2 Alzheimer’s disease
(AD) is the most common form of dementia,accounting for around 62% of cases.2
Nearly half of all people with AD have agi-tation symptoms every month.3 These arepositively correlated with institutionalisation,4
pharmacological treatment and use ofmedical services,3 but there is no evidenceon the costs of agitation in people withAD.5 6 The aim of this paper is to calculatethe monetary costs associated with agitationin AD.
METHODSParticipantsWe calculated National Health Service(NHS) and personal social services (PSS)costs associated with different levels of agita-tion using data from a naturalistic prospect-ive cohort study of people with AD, covering
Strengths and limitations of this study
▪ This study used detailed, prospectively collectedhealth and social care resource use data plusdata on frequency and severity of agitation symp-toms over a 54-month period to calculate thecosts of agitation in people with Alzheimer’sdisease (AD).
▪ There is no previous evidence about the cost ofagitation in AD, even though nearly half of allpeople with AD have agitation symptoms everymonth; this study calculated that the meanexcess cost associated with agitation per personwith AD was £4091 a year.
▪ A limitation of the study is that it is based on arelatively small data set of 224 people, recruitedto be representative of those with AD betweenJuly 2002 and January 2003 and followed up to54 months.
▪ We did not include the costs of informal care;these data were not collected and UK guidelinesfor undertaking economic evaluations recom-mend taking a health and social care perspectivewhen measuring costs.
Morris S, et al. BMJ Open 2015;5:e007382. doi:10.1136/bmjopen-2014-007382 1
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the London and the South East Region of the UK(LASER-AD study).3 7–9 Two hundred and twenty-fourpeople were recruited between July 2002 and January2003 and followed up to 54 months. The cohort was pur-posively and prospectively recruited, using overall figuresfrom a review of the epidemiology of AD, to be a repre-sentative sample of people with AD in terms of sex,living setting and severity of cognitive impairment in thecommunity.9 Participants and their carers wereapproached through local community mental healthteams, dementia specialist nurses, the voluntary sector,memory clinics, nursing and residential homes, day hos-pitals, day centres and inpatient units. Written informedconsent was obtained from all carers. Where the personwith AD lacked capacity to consent, the study only pro-ceeded if the carer consented and thought the personthey cared for would have agreed to participate if theycould. Measures were collected at baseline, and 18, 30,42 and 54 months after baseline. Data were obtainedfrom interviews with the patients with AD and theircarers, carried out at a place of their choice. They wereconducted by trained, experienced health professionals,and were terminated if the interviewee became dis-tressed or appeared to want to stop.
MeasuresThe Neuropsychiatric Inventory (NPI) uses responsesfrom caregivers in a structured interview format to assess10 behavioural domains (delusions, hallucinations, agita-tion, dysphoria, anxiety, apathy, irritability, euphoria, dis-inhibition, aberrant motor behaviour);10 two additionaldomains (night-time behavioural disturbance, appetite/weight changes) are commonly added, giving 12domains in total.11 Within each domain, behaviours arerated by caregivers in terms of frequency (1=occasionally—less than once per week, 2=often—about once perweek, 3=frequently—several times per week but less thanevery day, 4=very frequently—once or more per day)and severity (1=mild, 2=moderate, 3=severe). A score foreach domain is calculated as the product of the fre-quency and severity scores, giving nine possible values(0, 1, 2, 3, 4, 6, 8, 9, 12), including no symptoms (=0).A score >3 on any domain is usually regarded as clinic-ally significant.3 12–14 A total NPI score is obtained bysumming all the individual domain scores across the 12domains, giving a range from 0 to 144. Agitation wasassessed at each time point in the LASER-AD studyusing the agitation domain of the NPI, with highervalues indicating more severe levels of agitation.
Resource use and costingResource use was measured using the Client ServiceReceipt Inventory, amended for use with older people15
and collected from participant responses and caregiverreports for the previous 3 months at each time point.This incorporated information on where the person wasliving (at home, residential respite care, day respite care,residential care home (where staff typically do not have
nursing qualifications), nursing care home, shelteredhousing with a warden in the premises during the day,hospital awaiting placement), and their contacts withhealth and social care services (general practitioner(GP), practice nurse at the GP surgery, district nurse atthe person’s home, dietician, community psychiatricnurse, home help, meals on wheels, physiotherapist,chiropodist, optician, dentist, audiologist, psychologist,psychiatrist, day centre, hospital outpatient visits andinpatient stays). We did not include the costs of informalcare—these data were not collected; we focused onhealth and social care costs, which is the costing per-spective recommended in economic analyses in theUK.16 We applied unit costs from routine sources17 18 in2011 UK£ and calculated 3-month costs for each partici-pant at each follow-up point. Three-month costs weremultiplied by 4 to create 12-month figures.
Statistical analysesWe calculated unadjusted mean and median 12-monthcosts by NPI agitation score (≤3, >3) and examinedbetween-group differences using one-way analysis of vari-ance (ANOVA), and the Mann-Whitney two-sample test.We examined associations between NPI agitation scoreand demographic variables, coexisting conditions andcognitive impairment using χ2 tests. We calculateddescriptive statistics for caregivers, who assessed beha-viours using the NPI and recorded resource use. We cal-culated unadjusted mean and median 12-month costs byindividual NPI agitation score and tested for significantdifferences using one-way ANOVA with Bonferroni cor-rection for multiple tests, and χ2 tests on the equality ofmedians. Use of health and social services amongpeople with AD who are agitated may be affected by theextent of cognitive decline, demographic factors andcomorbidities; to isolate the costs associated with agita-tion, we ran analyses adjusting for these factors. Toaccount for skewness of the cost data, we used a general-ised linear model with γ family and log link,19 adjustingfor gender and age (using five 10-year bands) at base-line, marital status (6 categories), ethnic group (9 cat-egories), highest level of education (5 categories),previous employment (9 categories), rurality (2 categor-ies), coexisting conditions (diabetes, stroke, hyperten-sion, heart disease), total NPI agitation score (in ourdata the range of scores was 0–82 with 66 unique values;we included categorical indicators for each score, includ-ing 66 categories in total), cognitive impairment (mea-sured using the Mini-Mental State Examination;20 31categories), and follow-up point (baseline, 18, 30, 42,54 months). We also considered using log Normal,Gaussian, inverse Gaussian and negative binomial distri-butions, but the γ model gave the best fit in terms ofresidual plots and the Akaike Information Criterion. Weadjusted for clustering for repeated measures by partici-pant using clustered sandwich estimators for the SE thatallowed for intragroup correlation within participants.We predicted 12-month health and social care mean
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costs by NPI agitation score, controlling for the covari-ates. The differences in adjusted means were testedusing Wald tests. In intervention studies, outcomes aresometimes measured in terms of change in NPI agita-tion scores, so we re-ran the analyses including NPI agi-tation scores as a linear term rather than categoricalindicators.
Excess costs associated with agitationWe combined the adjusted annual costs per person atdifferent levels of NPI agitation score with prevalencerates in the LASER-AD study to calculate the annualexpected cost per person with AD based on the per centwith each NPI agitation score. From this, we subtractedthe adjusted annual costs per person with no agitationsymptoms (NPI score=0) to estimate the mean excesscosts associated with agitation per person each year. Wealso calculated UK-specific excess costs of agitationbased on the prevalence of AD in the UK.
RESULTSBaseline characteristics of caregiversThe mean age of caregivers (SD) was 63 years (14 years).Most caregivers were female (69%), married (69%), hadno children living at home (75%) and were living withthe person with AD (56%; see online supplementarytable S2). The modal relationship to the person with ADwas ‘Child’ (35%).
Health and social care costs associated with agitationOf the 224 participants in the LASER-AD study, 111 haddied by 54 months; our data set had 695 data points(person follow-ups). We applied unit costs to theresource use data in the LASER-AD study (see onlinesupplementary table S1). Unadjusted mean (SD) percapita annual costs for participants with NPI agitationscore ≤3 and >3 were £27 752 (£38 413) and £38 910(£46 150; p<0.001, table 1). Median (IQR) values were£24 796 (£3512–£38 656) and £28 492 (£11 680–£40 164;p=0.001). Cost data were highly skewed (see onlinesupplementary figure S1). The mode and median NPIagitation score were 0 and 1, respectively (table 2).Table 1 shows the per cent of the sample with differentdemographic variables, coexisting conditions and cogni-tive impairment by NPI agitation score. People with agi-tation scores >3 had a higher mean and median totalNPI score, were more likely to be single and divorcedand less likely to be married, less likely to be educatedto secondary level and more likely to be educated to ter-tiary level, more likely to have heart disease, and morelikely to have severe cognitive impairment (p<0.05).Unadjusted mean and median costs increased with
agitation score (p≤0.001; table 2).After adjusting for demographic variables, coexisting
conditions, cognitive impairment, follow-up and individualclustering for repeated measures, mean costs varied byNPI agitation scores, from £29 000 over a 12-month period
with no agitation symptoms (NPI agitation score=0) up to£57 000 at the most severe levels of agitation (NPI agitationscore=12; p=0.01, table 2 and figure 1). Costs also variedsignificantly by age and gender, marital status, ethnicgroup, highest level of education, total NPI score and cog-nitive impairment (p<0.05, see online supplementarytable S3).When we reran the model including NPI agitation
scores as a linear term rather than categorical indicators,we found that a one-unit increase in NPI agitation scoreswas associated with a £1736 increase in costs per patientover a 12-month period (95% CI £644 to £2807, p=0.001)in an unadjusted model, and £1064 (95% CI −£34 to£2162, p=0.058) when adjusting for the covariates.
Excess costs associated with agitation in the UKThe adjusted annual expected cost per person with ADbased on the per cent with each NPI agitation score inour sample was £33 075 and the adjusted annual costsper person with no agitation symptoms was £28 983 (seeonline supplementary table S4). Hence, the excess costassociated with agitation per person with AD was £4091a year. This suggests that on average agitation accountsfor 12% (£4091/£33 075) of the health and social carecosts of AD each year. In the UK, there are 800 000people with dementia and around 62% of cases areaccounted for by AD.2 The expected excess cost asso-ciated with agitation in people with AD is therefore £2.0billion a year (£4091×800 000×0.62).
DISCUSSIONPrincipal findingsAmong people with AD, health and social care costsvaried significantly by the level of agitation, from£29 000 over a 12-month period in people with no agita-tion symptoms up to around £57 000 at the most severelevels of agitation. On average, agitation symptomsaccount for 12% of the health and social care costs ofAD. The excess cost associated with agitation was £2billion a year across all people with AD in the UK.
Strengths and weaknessesOur analysis is based on a unique data set containingvery detailed information on frequency and severity ofagitation symptoms and use of health and social care ser-vices over a 54-month time period. The data alsoinclude a range of demographic variables, coexistingconditions and cognitive impairment that can beincluded to isolate the costs associated with agitation.With regard to limitations, the data set is relatively
small, containing 224 people with AD. Given the largenumber of covariates included in our models, the factthat agitation is a significant predictor of costs suggeststhat the relationship is a strong one. Participants wererecruited between July 2002 and January 2003 and fol-lowed up to 54 months; hence, the data are relatively oldand the prevalence of agitations symptoms among
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people with AD may have changed over time. In add-ition, management practices might have changed overtime. For example, in 2006, the National Institute forHealth and Care Excellence in England first publishedguidance on the use of medications and treatments forAD; this was amended in 2007 and 2009, and newupdated guidance that recommended extending the useof drug treatment in AD was issued in 2011.21
Prescribing practices have changed over time with amarked reduction in antipsychotic drug use in peoplewith dementia: the mean prevalence of antipsychoticuse on diagnosis of dementia fell in the UK from 19.9%in 1995 to 7.4% in 2011.22 While participants wereselected to be representative of patients with AD, theywere recruited from one geographical area, potentiallylimiting generalisability. We did not include the costs ofinformal care, though these have been estimated toaccount for a substantial proportion of the total costs ofdementia.1 2 23 These data were not collected in theLASER-AD study. UK guidelines for undertaking eco-nomic evaluations recommend taking a health andsocial care perspective when measuring costs.16
Comparison with other studiesSeveral studies have evaluated the relationship betweenbehavioural symptoms and costs of care associated withAD, but none have specifically evaluated the monetarycost of agitation in AD. The studies evaluating theimpact of behavioural symptoms on costs of care havetended to find a positive relationship. For example,using data from the USA on 128 patients with ADMurman et al24 found that after controlling for cognitiveimpairment and comorbidities behavioural symptomsmeasured using the NPI significantly increased totaldirect costs (healthcare costs plus informal care costs): aone-point increase in total NPI score was associated withan annual increase of between US$247 and US$409 intotal direct costs, depending on the value of unpaidcaregiving. Gustavsson et al found that in a sample of1222 patients with AD from Spain, Sweden, the UK, andthe USA, there was a significant relationship betweenbehavioural symptoms measured using total NPI scoreand cost of health and social care among people livingin the community after controlling for ability to performactivities of daily living and cognitive impairment: a one-
Table 1 Continued
NPI agitation score ≤3 (N=493) NPI agitation score >3 (N=202) p Value
point increase in total NPI score was associated with a1% increase in health and social care costs. Amongpeople living in residential care, a one-point increase intotal NPI score was associated with a 1.6% increase incosts of care in the USA only.25 Using data for 272patients with AD attending six memory clinics inSweden, Denmark, Norway and Finland, Jönsson andEriksdotter Jönhagen26 found that total NPI score wassignificantly associated with health and social care plusinformal care costs: after controlling for cognitiveimpairment, years since diagnosis of AD and comorbid-ities costs were calculated to increase by 8% for eachone-point increase in total NPI score.
Implications for clinicians and policymakersPeople with AD who are agitated are substantial users ofhealth and social care services, suggesting that effectivemeasures to reduce agitation would reduce the burdenon these services, as well as providing health benefits topeople with AD and their carers. Reducing agitationcould be cost-effective and, in addition, bring consider-able cost savings, which should be compared against thecost of interventions.
Further researchHealth economic analyses of interventions for reducingagitation in AD incorporated into clinical trials areneeded. Such analyses should evaluate the impact of inter-ventions using final outcomes such as quality-adjusted lifeyears, for example, using new approaches based on theDEMQOL system,27 28 where cost-effectiveness thresholdshave been identified.16 They should also include compre-hensive cost analyses, including health and social carecosts associated with managing agitation as well as
intervention costs, and be conducted over sufficiently longtime horizons to measure the full costs and benefits.
Author affiliations1Department of Applied Health Research, University College London, London,UK2Department of Statistical Science and PRIMENT Clinical Trials Unit,University College London, London, UK3Division of Psychiatry, University College London, London, UK
Acknowledgements The authors would like to thank Shirley Nurock,dementia family carer, for her thoughts and contributions.
Contributors GL and CC initiated the study. SM and GL designed theanalysis. GL and CK obtained the LASER-AD data. LK and EL-H locatedreferences and extracted data. NP identified unit costs and applied them to thedata. SM ran the statistical analyses with input from GB and RZO. SM draftedthe paper.
Funding This article presents independent research commissioned by the UKNational Institute for Health Research (NIHR) Health Technology AssessmentProgramme: HTA 10/43/01. The study was sponsored by UCL.
Competing interests None.
Ethics approval Local Research Ethics Committees approved the study.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
Open Access This is an Open Access article distributed in accordance withthe terms of the Creative Commons Attribution (CC BY 4.0) license, whichpermits others to distribute, remix, adapt and build upon this work, forcommercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/
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Online supplements Table S1. Unit costs Table S2. Baseline characteristics of caregivers (N=224) Figure S1. Distribution of per capita annual cost (N=695) Table S3. Association between agitation symptoms and per capita annual cost: adjusted analyses, full results (N=695) Table S4. Calculation of excess costs associated with agitation in people with Alzheimer’s disease
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Table S1. Unit costs
Cost component Unit costa Unit Reference
General Practitioner (GP) 36 Per surgery consultation 17
Practice nurse/District nurse 60 Per hour 17
Dietician 35 Per hour 17
Community psychiatric nurse 50 Per hour 17
Occupational therapist 82 Per hour 17
Home help 27 Per hour 17
Meals on wheels 6. Per meal 17
Physiotherapist 34 Per hour 17
Chiropodist 31 Per hour 17
Optician 57 Per contact 18
Dentist 92 Per contact 18
Audiologist 67 Per contact 18
Psychiatrist 418 Per contact 17
Psychologist 135 Per hour 17
Day centre 34 Per visit 17
Hospital outpatient visit 100 Per visit 17
Hospital inpatient stay 321 Per day 17
Residential respite care 105 Per overnight stay 17
Day respite care 96 Per day 17
Residential care home 519 Per week 17
Nursing care home 741 Per week 17
Sheltered housing 155 Per week 17
Hospital awaiting placement 321 Per day 17
a 2011 UK£.
3
Table S2. Baseline characteristics of caregivers (N=224) Characteristic Baseline value (N=224)
Age (years)
Mean (SD) 63 (14)
Gender (%)
Male 31
Female 69
Marital status (%)
Single/unmarried 9
Married 69
Co-habiting 2
Widowed 5
Separated/divorced 7
Not known 8
Number of children at home (%)
0 75
1 8
2 7
3 2
4 1
Not known 7
Living with person with AD (%)
Yes 56
No 43
Not known 1
Relationship to person with AD (%)
Husband/partner 17
Wife/partner 20
Child 35
Friend 4
Other relative 9
Paid carer 14
Abbreviation: AD, Alzheimer’s disease
4
Figure S1. Distribution of per capita annual cost (N=695)
Tests for normality: Shapiro–Wilk normality test: P <0.01. Shapiro–Francia normality test: P <0.01.
01
02
03
04
0P
erc
en
t
0 50000 100000 150000 200000 250000 300000Total annual cost per person (2011 UK£)
5
Table S3. Association between agitation symptoms and per capita annual costa: adjusted analyses, full results (N=695)
Adjusted mean (95% CI)
NPI agitation scores
0 28 983 ( 24 364 to 33 603 )
1 43 910 ( 30 618 to 57203 )
2 31 196 ( 22 903 to 39 490 )
3 35 120 ( 25 592 to 44 648 )
4 35 458 ( 26 843 to 44 074 )
6 25 138 ( 17 918 to 32 358 )
8 36 568 ( 25 590 to 47 545 )
9 38 568 ( 11 867 to 65 269 )
12 57 023 ( 31 861 to 82 186 ) P value 0.01
Gender*age category (years) .
Male*60-69 106 172 ( 22 527 to 189 816 )
Male*70-79 20 838 ( 14 560 to 27 116 )
Male*80-89 27 740 ( 18 508 to 36 971 )
Male*90-99 37 134 ( 9778 to 64 490 )
Female*50-59 58 633 ( -23 297 to 140 563 )
Female*60-69 20 663 ( 8848 to 32 477 )
Female*70-79 30 443 ( 22 400 to 38 487 )
Female*80-89 43 813 ( 34 943 to 52 683 )
Female*90-99 36 165 ( 23 067 to 49 264 ) P value <0.001
Marital status
Single 61 977 ( 32 527 to 91 427 )
Married 22 821 ( 18 359 to 27 283 )
Separated 33 384 ( 6357 to 60 411 )
Divorced 28 087 ( 13 377 to 42 797 )
Widower 36 598 ( 30 183 to 43 013 )
Other 72 443 ( 14 808 to 130 077 ) P value 0.002
Ethnic group
White British 31 901 ( 27 905 to 35 896 )
White Irish 28 072 ( 16 285 to 39 859 )
White other 37 326 ( 23 133 to 51 518 )
Greek 2763 ( -960 to 6486 )
Black Caribbean 59 761 ( 25 301 to 94 220 )
Black other 35 488 ( -912 to 71 888 )
Indian 4226 ( 166 to 8286 )
Pakistani 63 600 ( 23 645 to 103 556 )
Other 39 098 ( 14 420 to 63 776 ) P value <0.001
Highest level of education
Primary 32 855 ( 3512 to 62 198 )
Secondary 33 992 ( 29 155 to 38 829 )
Tertiary 36 291 ( 16 018 to 56 565 )
Other 3136 ( 1207 to 5065 )
Not known 22 863 ( 17 604 to 28 122 ) P value <0.001
Annual expected cost per person with AD based on percent with each NPI agitation score = 45.2%*£28 983 + 9.8%*£43 910 + 8.6%*£31 196 + 7.3%*£35 120 + 8.6%*£35 458 + 8.2%*£25 138 + 6.5%*£36 568 + 1.7%*£38 568 + 4.0%*£57 023 = £33 075 Annual cost per person with AD with no agitation symptoms (NPI agitation score =0) = £28 983. Mean excess cost associated with agitation per person with AD each year = £33 075 - £28 983 = £4091. Number of people with dementia in the UK = 800 000; around 62% (= 496 000) are accounted for by AD. Excess cost associated with agitation in people with AD in the UK each year = £3265*800 000*0.62 = £2.0 billion.