Dementia Care Practice

Objective: Few studies have investigated trajectories in care among patients with Alzheimer's Disease (AD), especially Veterans who experience a unique set of AD risk factors and challenges in access to AD immunotherapy in the Veterans Affairs Healthcare System (VAHS) of the United States.

Methods: We analyzed trajectories in care based on electronic health records (EHR) among Veterans who were assessed for AD based on ICD-10 coding within the VAHS between Oct 2015 and Jan 2024. Among Veterans with an ICD-10 code for AD in the VAHS, we examined frequency distributions of clinical visits by physician specialty (primary care, neurologist, geriatrician, psychiatrist, and other specialties) where the initial AD ICD-10 coding was recorded. Transition to the specialist care or visit to a dementia clinic was calculated during the year after the initial ICD-10 coding for AD from the initial visit to a primary care physician. Distribution of the transition to specialist care was examined across non-Hispanic Black, non-Hispanic White, Hispanic, and other race/ethnicity groups.

Results: A total of 110,836 Veterans were identified by ≥1 ICD-10 code for AD with a subsample of 71,666 seen by a clinician with known specialty. Mean age was 80.7 years, 97.3% were male, 11.6% non-Hispanic Black, 8.2% Hispanic, and 70.7% non-Hispanic White. More than 41% of the initial AD coding was assigned in the primary care physician, 9% in neurologist, 8% geriatrician, and 12% psychiatrist. In the subsample of 71,666 Veterans within one year, 26.4% had a subsequent visit to a neurologist office or Dementia clinic. Among Veterans initially seen in primary care for AD, 31.7% non-Hispanic Black (p<0.01) and 25.3% Hispanic (p = 0.22), relative to 23.9% non-Hispanic White, were subsequently visited a neurologist or a dementia clinic.

Conclusions: Over 40% more Veterans were initially evaluated for AD by a primary care clinician than by an AD specialist including neurologists, psychiatrists, and geriatricians. Non-Hispanic Black Veterans were more likely to follow up with a neurologist or at a dementia clinic compared to Hispanic or non-Hispanic White Veterans during the year after the initial AD assessment. The findings suggest a need for further enhancement of AD care trajectory.