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Original Investigation
November 30, 2020

Financial Presentation of Alzheimer Disease and Related Dementias

Author Affiliations
  • 1Johns Hopkins School of Public Health & School of Medicine, Institute for Social Research, Baltimore, Maryland
  • 2University of Colorado School of Public Health
  • 3Institute for Social Research, University of Michigan Medical School, Ann Arbor, Michigan
  • 4University of Michigan Medical School, Ann Arbor
  • 5Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
  • 6Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
  • 7Federal Reserve Board of Governors & Howard University, Washington, DC
  • 8Howard University
JAMA Intern Med. 2021;181(2):220-227. doi:10.1001/jamainternmed.2020.6432
Key Points

Question  Are Alzheimer disease and related dementias (ADRD) associated with adverse financial outcomes in the years before and after diagnosis?

Findings  In this cohort study of 81 364 Medicare beneficiaries living in single-person households, those with ADRD were more likely to miss bill payments up to 6 years prior to diagnosis and started to develop subprime credit scores 2.5 years prior to diagnosis compared with those never diagnosed. These negative financial outcomes persisted after ADRD diagnosis, accounted for 10% to 15% of missed payments in our sample, and were more prevalent in census tracts with less college education.

Meaning  Alzheimer disease and related dementias were associated with adverse financial events starting years prior to clinical diagnosis.


Importance  Alzheimer disease and related dementias (ADRD), currently incurable neurodegenerative diseases, can threaten patients’ financial status owing to memory deficits and changes in risk perception. Deteriorating financial capabilities are among the earliest signs of cognitive decline, but the frequency and extent of adverse financial events before and after diagnosis have not been characterized.

Objectives  To describe the financial presentation of ADRD using administrative credit data.

Design, Setting, and Participants  This retrospective secondary data analysis of consumer credit report outcomes from 1999 to 2018 linked to Medicare claims data included 81 364 Medicare beneficiaries living in single-person households.

Exposures  Occurrence of adverse financial events in those with vs without ADRD diagnosis and time of adverse financial event from ADRD diagnosis.

Main Outcomes and Measures  Missed payments on credit accounts (30 or more days late) and subprime credit scores.

Results  Overall, 54 062 (17 890 [33.1%] men; mean [SD] age, 74 [7.3] years) were never diagnosed with ADRD during the sample period and 27 302 had ADRD for at least 1 quarter of observation (8573 [31.4%] men; mean [SD] age, 79.4 [7.5] years). Single Medicare beneficiaries diagnosed with ADRD were more likely to miss payments on credit accounts as early as 6 years prior to diagnosis compared with demographically similar beneficiaries without ADRD (7.7% vs 7.3%; absolute difference, 0.4 percentage points [pp]; 95% CI, 0.07-0.70:) and to develop subprime credit scores 2.5 years prior to diagnosis (8.5% vs 8.1%; absolute difference, 0.38 pp; 95% CI, 0.04-0.72). By the quarter after diagnosis, patients with ADRD remained more likely to miss payments than similar beneficiaries who did not develop ADRD (7.9% vs 6.9%; absolute difference, 1.0 pp; 95% CI, 0.67-1.40) and more likely to have subprime credit scores than those without ADRD (8.2% vs 7.5%; absolute difference, 0.70 pp; 95% CI, 0.34-1.1). Adverse financial events were more common among patients with ADRD in lower-education census tracts. The patterns of adverse events associated with ADRD were unique compared with other medical conditions (eg, glaucoma, hip fracture).

Conclusions and Relevance  Alzheimer disease and related dementias were associated with adverse financial events years prior to clinical diagnosis that become more prevalent after diagnosis and were most common in lower-education census tracts.

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    1 Comment for this article
    Aging, Vulnerability and Fraud - This Study Further Explains It
    David Kirkman, JD | Retired consumer frauds prosecutor and former manager of elder fraud unit, North Carolina Department of Justice
    Having worked in the elder fraud unit of a major law enforcement agency for two decades, I can confirm that financial advisers and bank personnel are among the first to spot and report declining financial competency and the frauds and scams that often accompany it. My coworkers and I also could perceive a pattern whereby declining financial skills and an inability to protect oneself from scams and frauds often preceded an Alzheimer's diagnosis by 3-4 years. That pattern, which this and other recent medical studies tend to confirm, makes sense to laypersons like me. Financial skills are much more complex and abstract and require far more cognitive firepower than other day-to-day activities and decisions.

    Who regularly spots and exploits declining financial competency and other age-related vulnerabilities long before family members, bankers and other financial professionals? The elder fraud industry. Studies like this should help us to catch up with the elder fraud industry and perhaps spot these vulnerabilities before the criminals can inflict significant financial and psychological damage upon their targets.

    Thanks to the authors for their hard work and for their interest in this important and challenging topic.

    David Neil Kirkman