Age-related memory loss is common, but more severe memory problems may be a sign of dementia, which is not a normal part of aging.
“Dementia is a set of symptoms that manifest as cognitive changes that are severe enough to affect your daily activities and daily functioning so that you are no longer able to do the things you used to do because of your thinking ability,” Ronald C. said Dr. Peterson, Ph.D., M.D., director of the Alzheimer’s Disease Research Center and the Mayo Clinic Aging Research Center at the Mayo Clinic in Rochester, Minnesota.
Dementia is on the rise in the United States, with 14 million cases expected by 2060. According to the Alzheimer’s Association, approximately 6.9 million Americans age 65 and older will have Alzheimer’s disease by 2024, accounting for 10.9% of those 65 and older.
Alzheimer’s disease occurs when amyloid, a naturally occurring protein in the body, clumps together to form amyloid plaques in the brain, which affects memory and thinking ability.
Other types of dementia that affect people over 65 include Lewy body dementia (caused by abnormal deposits of alpha-synuclein proteins called Lewy bodies), vascular dementia (caused by damage to blood vessels in the brain or Caused by disruption of the flow of oxygen and blood to the brain, and mixed dementia, a combination of at least two types of dementia.
People with dementia have a variety of medical problems. “In addition to the symptoms associated with dementia, the vast majority of people with dementia suffer from one or more chronic health conditions,” said Matthew Baumgart, vice president of health policy at the Alzheimer’s Association. .
Medicare (and Medicare Advantage) provide some coverage for dementia starting from diagnosis, Baumgart said.
diagnosing dementia
The annual Medicare Wellness Exam is free to Medicare beneficiaries and includes a cognitive assessment. If your doctor has any concerns, you may be referred to a specialist or revisit your doctor for a clinical evaluation to determine whether you have cognitive impairment. This appointment is covered by Medicare Part B and may be subject to a copay and/or deductible.
During the evaluation, “doctors will ask about the medical history of the patient and people who know the patient well to see if there have been changes in memory, thinking, behavior or functioning,” Peterson said. “The doctor will also conduct a mental status examination, which may include asking the patient to memorize words, arithmetic, the name of the current president, draw boxes and other exercises to roughly assess a person’s cognitive function.” said. “If necessary, doctors can do additional cognitive testing to look more closely at memory, attention, language, visuospatial skills. Then all that information is put together and evaluated,” Peterson said.
Dementia Care Plan
Once diagnosed with dementia, patients can live many years, Peterson said. Symptoms can get worse over time, which is why having a care plan is important, he said.
The Alzheimer’s Association is a strong advocate for coverage under Medicare’s Dementia Care Plan, and since 2017, Medicare Part B has paid for individual visits with a doctor or specialist to plan care for patients diagnosed with dementia plan.
A dementia care plan can include recommended treatments and therapies for dementia symptoms and other health conditions, safety advice, care support, end-of-life planning, and more.
Drugs to Treat Dementia
While there is no cure for any type of dementia, medications may help reduce symptoms and/or prevent further cognitive decline.
All Medicare drug plans must cover at least two prescription drugs called cholinesterase inhibitors. These drugs treat Alzheimer’s disease by helping to improve memory, attention, reasoning and language, as well as increasing levels of brain chemicals that aid memory and judgment.
In 2023, lecanemab (trade name: Leqembi) was approved by the FDA for the treatment of mild cognitive impairment and mild Alzheimer’s disease. “This drug is injected intravenously into a vein, circulates into the bloodstream, then enters the brain and activates the immune system to clear some of the amyloid plaques in the brain,” Peterson said.
Leqembi is covered by Medicare Part B if a PET scan confirms the presence of amyloid plaques in the brain and the patient is enrolled. The registry collects evidence about how medicines work in the real world, which clinicians submit through a national portal.
As of late 2023, the cost of a PET scan specifically to determine this condition is covered by Medicare Part B. . The out-of-pocket cost for diagnostic testing under Medicare is typically 20% of the cost after the annual deductible.
In July 2024, donanemab, sold under the brand name Kisunla, received FDA approval. It is also an intravenous drug, covered by Medicare, that identifies amyloid plaques in the brain through PET scans and is registered by the patient on a registry.
Both Leqembi and Kisunla are covered by Medicare Part B, which means Medicare beneficiaries do not have to be enrolled in Medicare Part D to get coverage for these prescriptions. Covered people still have to pay a 20% out-of-pocket cost, and both drugs are expensive. Leqembi’s manufacturer lists the cost at $26,500 per year. The manufacturer of Kisunla lists the cost of 12 months of treatment at $32,000.
The Inflation Reduction Act of 2022 could provide some relief. Starting in 2025, the law caps out-of-pocket Part D drug costs at $2,000.
Medicare coverage for long-term and personal care related to dementia
“Unfortunately, Medicare does not cover some critical services for people with dementia, including long-term care and personal care,” Baumgart said. He said long-term care includes residences in assisted living facilities, adult day care and nursing homes for stays of more than 100 days. Personal care includes assistance with activities of daily living including cooking, assistance with bathing and dressing.
“Medicare does offer skilled nursing home care coverage for specific specialty treatments, such as physical, occupational or speech therapy, or occasional skilled nursing care,” Baumgart said. Doctors must certify that the patient is home and needs this help, and it must be provided by a Medicare-approved home health agency, he said.
If a person with dementia is enrolled in both Medicare and Medicaid, Medicaid may pay for some or all of the services that Medicare does not cover. Medicaid can also pay some or all of Medicare’s premiums, copays, and deductibles.
“Medicare does cover hospice care, the final stage of dementia,” Baumgart said.
New plan to help people with dementia
Two government measures are launching efforts to provide additional assistance to people with dementia. These include the Biden administration’s April 2023 Executive Order 14095 on increasing access to high-quality care and supportive caregivers and the national plan to address Alzheimer’s disease,
One program that meets both measures is the GUIDE model, which launches on July 1, 2024 as a Medicare pilot program.
“We’re excited about this,” Baumgart said. “It provides people with dementia and their caregivers the ability to more seamlessly navigate the health care and social support systems,” he said.
The program will provide additional health insurance coverage, including care coordination and care management, caregiver education and support, and respite services.
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