Alzheimers disease—doesn’t say what you think it says

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2020.6432?guestAccessKey=807ca0d3-63aa-48f9-8a1d-16df0d828d42&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=113020

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

I listen to a podcast and read articles and it seems omg this is great!! Maybe we look to see if people are missing payments or making poor financial decisions and screen them for alzheimers. Currently screening for alzheimers is difficult because we don’t have good treatment to slow or prevent the progression of the disease.

Remember a few basic principles of screening are

The condition should be an important health problem.
There should be a treatment for the condition that can change the outcome.
Total cost of finding a case should be economically balanced in relation to medical expenditure as a whole.
As I say those I cant think can we apply those to covid screening?? (say it again)

retrospective secondary data analysis of consumer credit report outcomes from 1999 to 2018 linked to Medicare claims data of 81 364 individuals

and they were looking for Missed payments on credit accounts (30 or more days late) and subprime credit scores.

Does an individual with Alzheimer disease and related dementias miss more financial payments than those individuals without alzheimers and they found

“Alzheimer disease and related dementias were associated with adverse financial events years prior to clinical diagnosis that become more prevalent after diagnosis”

But lets look at some of the results—


Overall, 54 062 pts without the diagnoses of ADRD were included and 27 302 who had the diagnosis of ADRD were included.
Those Medicare beneficiaries diagnosed with ADRD were more likely to miss payments on credit accounts at a rate of 7.7% compared to only 7.3% of missed payments in those individuals without a diagnosis of ADRD (7.7% vs 7.3%; absolute difference, 0.4 percentage points [pp]; 95% CI, 0.07-0.70:). You might say wait a second a 0.4 percent absolute difference is statistically significant?? Yes, remember the more people you have in a study the more likely even a very very very small difference is statistically significant.

This study also looked at those individuals who develop subprime credit scores 2.5 years prior to diagnosis – for those individuals with ADRD this occurred 8.5% of the time compared to only 8.1% of the time in those individuals without the diagnosis of ADRD. This was an absolute difference, 0.38 pp; 95% CI, 0.04-0.72

Once again this is statistically significnat because so many people were enrolled. HOWEVER here is the problem and somehitng to notice. The authors gave you percent here, not the actual number which is what you are a question medicine individual needs to know! The reason being is because it drastically changes the outcome and results

Lets look at the first outcome of miss payments on credit account, this occurred 7.7% of those with ADRD compared to only 7.3% of missed payments in those individuals without a diagnosis of ADRD. BUT REMEMBER the people that were enrolled in this study- 54 062 pts without the diagnoses of ADRD were included and 27 302 who had the diagnosis of ADRD were included

This mean you have to take 7.7% of 27000 patients with a dx of ADRD
And 7.3% of 54000 patients without a dx of ADRD

This works out to a total of 6000 patients but it breaks down to 2000 individuals diagnosed with ADRD missed a credit card payment and 4000 individuals without a diagnosis of ADRD missed a credit card payment. So 2/3 of individuals who missed a credit card report did not have a diagnosis of ADRD!!

When you look at the second outcome of a subprime credit score you find almost the same thing! Remember the results were 8.5% vs 8.1% WHICH CLEARLY shows that those individuals with alheimers dementia diagnosis are more like to develop a subprime credit score but when you look at 8.5% of 27000 and 8.1% of 54000 it is clear at 8.1% of 54000 is a much bigger number so the actual numbers work out to almost 2/3 of those indivudials with a subprime credit score DO NOT have diagnosed dementia.


The authors say in the discussion that the findings “suggest that ADRD is associated with adverse financial outcomes even in the prediagnosis stage”

Yes they are right it is associated with adverse outcomes, but so is breathing!! So it brushing your teeth, more people without ADRD had or made poor financial decisions than those with ADRD.

The outcomes of this paper would change drastically if they ssaid we looked at the numbers and out of almost 80,000 patients it turns out that of those individuals who missed a credit card payment or a had subprime credit score 1/3 of the time these individuals had ADRD and 2/3 of the time they did not have.

This is a drastically different conclusion than what the authors said which was

“ Alzheimer disease and related dementias were associated with adverse financial events years prior to clinical diagnosis”


I think the take home is we still don’t have good screening for alzheimer disease and looking at adverse financial events is still not the magic bullet of alzheimers screening. AND don’t be confused if the authors don’t give you the exact numbers.. if they give you percent or ratios then you need to calculate the numbers yourself because likely they are trying to hide something or spin the results