American Journal of Alzheimer's Disease and Other Dementias current issue

Review of Issue: Strategies for Patient Diagnosis and Management

Lippa, C. F. — 2009-06-24

Review: Donepezil in Severe Alzheimer's Disease

Winblad, B. — 2009-06-24

In the severe stages of Alzheimer's disease, functional autonomy is lost, psychiatric and behavioral symptoms become increasingly troublesome, and cognitive deficits increase until most patients require complete care, usually in specialized nursing homes. Consequently, some health care professionals question the benefits of pharmacologic intervention during these later stages. Since primary care physicians are often first to see these patients, they have key roles in recognizing the benefits of treatment and initiating appropriate management and referral. Three prospective randomized clinical trials of donepezil in severe Alzheimer's disease have been conducted; these show donepezil treatment is associated with functional and cognitive benefits, although behavioral benefits were not consistently observed. Donepezil was well tolerated; side effects were transient, mild to moderately severe, and cholinergic in nature. Donepezil has strong data throughout the Alzheimer's disease spectrum and, therefore, represents a first-line monotherapy that can provide benefits to patients in all stages of Alzheimer's disease.

The Effects of a Dementia Nurse Care Manager on Improving Caregiver Outcomes Outcomes

Specht, J., Bossen, A., Hall, G. R., Zimmerman, B., Russell, J. — 2009-06-24

Iowa's Administration on Aging's Alzheimer's Disease Demonstration Grant to the States was a project to implement and evaluate a nurse care management model of service delivery for persons with dementia or care recipient and their family caregiver that was integrated with the case management system. The goal of the nursing service delivery model was to maintain persons with dementia safely in their homes, by connecting them with appropriate services and providing support to the care recipient and caregivers. Outcomes measures were evaluated over time. This article defines the role of dementia nurse care management and shares the results of the outcomes measurements. The evaluation showed that caregivers assisted by nurse care managements were more likely to show improvement in their stress levels, endurance potential, and well-being. This improvement was consistent over time.

A Framework for Managing Wandering and Preventing Elopement

Moore, D. H., Algase, D. L., Powell-Cope, G., Applegarth, S., Beattie, E. R. A. — 2009-06-24

Purpose of the Study: A framework aids choice of interventions to manage wandering and prevent elopement in consideration of associated risks and mobility needs of wanderers. Design and Methods: A literature review, together with research results, published wandering tools, clinical reports, author clinical experience, and consensus-based judgments was used to build a decision-making framework. Results: Referencing a published definition of wandering and originating a clinical description of problematic wandering, authors introduce a framework comprising (1) wandering and related behaviors; (2) goals of wandering-specific care, (3) interpersonally, technologically, and policy-mediated wandering interventions, and (4) estimates of relative frequencies of wandering behaviors, magnitudes of elopement risk, and restrictiveness of strategies. Implications: Safeguarding wanderers from elopement risk is rendered person-centered and humane when goals of care guide intervention choice. Despite limitations, a reasoned, systematized approach to wandering management provides a basis for tailoring a specialized program of care. The need for framework refinement and related research is emphasized.

Frontal-executive Versus Posterior-perceptual Mental Status Deficits in Early-onset Dementias

Mendez, M. F., McMurtray, A. M., Licht, E. A., Saul, R. E. — 2009-06-24

Background: Compared to late-onset dementias, early-onset dementias (EODs) may have greater focal cognitive involvement with differences in frontal-executive compared to posterior-perceptual deficits. Objective: This study evaluated whether mental status screening based on this frontal-posterior axis can distinguish EODs. Methods: Twenty-three patients each with early-onset Alzheimer's disease (eAD), frontotemporal dementia (FTD), or subcortical ischemic vascular disease (SIVD), and 20 normal controls underwent the Frontal Assessment Battery (FAB) and the Perceptual Assessment Battery (PAB). Results: Compared to controls, SIVD and FTD groups were impaired on the FAB whereas eAD and SIVD groups were impaired on the PAB. The FAB/PAB ratio further differentiated the groups (F(3,85) = 26.49, P < .001). For sensitivities and specificities of 93%, a cut-off score of 1.25 on the FAB/PAB distinguished eAD, and a cut-off of 0.83 distinguishing FTD. Conclusion: Although preliminary, this study indicates that mental status screening based on frontal versus posterior cortical functions may help clinicians diagnose EODs.

Treatment Characteristics of Patients With Dementia: Comparing Two Different Psychiatric Inpatient Settings

2009-06-24

Objective: Patients with dementia in 2 German community psychiatric hospitals with different treatment settings were investigated prospectively and treatment variables compared. Method: In each of the hospitals, which differ in treatment settings (Gütersloh specialized vs. Detmold integrated), 50 patients with dementia consecutively admitted were screened and compared according to personal data, clinical instruments, medication, and diagnosis. Results: No relevant differences were found in the basic characteristics, average age was high (79 years), and patients were significantly restrained in functionality and cognitive functioning. Patients of Gütersloh were transferred to institutional care less frequently. Overall morbidity was high and little improvement in functioning at discharge was recorded. Conclusions: Data of this prospective study show that dementia patients were significantly restrained in cognitive and daily functioning along with high morbidity. Discharge to institutional care and discharge medication was reduced in patients of the special dementia care setting.

Preserving Cognition Through an Integrated Cognitive Stimulation and Training Program

Eckroth-Bucher, M., Siberski, J. — 2009-06-24

Background: Cognitive decline leads to disability and increased health care expenditures. Methods: Effectiveness of an intervention to stimulate multiple cognitive domains was determined using a format combining traditional and computer-based activities (Integrated Cognitive Stimulation and Training Program), 45 minutes a day, 2 days a week, for 6 weeks. Nonimpaired, mildly, and moderately-impaired participants > age 65 (n = 32) were randomly allocated into a control or experimental group. Using a repeated measures design participants were tested again postintervention and at 8 weeks follow-up. Results: Statistically significant improvement on Dementia Rating Scale scores occurred for mildly and moderately impaired treatment participants (n = 15). Statistical significance was demonstrated on subscales of the WMS-III: Logical Memory I and Logical Memory II. Conclusion: Blending computer-based with traditional cognitive stimulation activities shows promise in preserving cognitive function in elders. Future studies to explore efficacy in larger, more diverse samples are needed.

Persons With Moderate Alzheimer's Disease Improve Activities and Mood via Instruction Technology

2009-06-24

Background: Three studies assessed the (a) effectiveness of verbal instructions presented via technology in helping persons with moderate Alzheimer's disease perform daily activities and (b) impact of activity engagement on mood. Methods: The 3 studies targeted coffee preparation with 2 women, use of make-up with 2 women, and use of make-up and tea preparation with 3 women. Intervention effects on activity performance were assessed through nonconcurrent multiple baseline designs across participants or multiple baseline designs across activities. The impact of activity on mood was assessed by recording indices of happiness during activity trials and parallel nonactivity periods. Results: Verbal instructions presented via technology were effective in helping all participants perform the target activities. The participants also showed mood improvement (ie, increases in indices of happiness) during the activity. Conclusion: These results suggest that the approach reported may be a useful strategy for helping persons with Alzheimer's disease.

Eye Tracking During a Visual Paired Comparison Task as a Predictor of Early Dementia

2009-06-24

The authors present findings from a behavioral task (visual paired comparison) using infrared eye-tracking that could potentially be useful in predicting the onset of Alzheimer's disease. Delay intervals of 2 seconds and 2 minutes were used between the initial viewing of a picture and when the picture was displayed alongside a novel picture. Eye-tracking revealed that at the 2-second delay, 6 patients with mild cognitive impairment, 15 matched control participants (normal control), and 4 neurological control participants with Parkinson's disease performed comparably, viewing the novel picture greater than 71% of the time. When the delay increased to 2 minutes, patients with mild cognitive impairment viewed the novel picture only 53% of the time (P < .05), while control participants and participants with Parkinson's disease remained above 70%. These findings demonstrate the usefulness of this task for assessing normal as well as impaired memory function.

Switching from Donepezil Tablets to Rivastigmine Transdermal Patch in Alzheimer's Disease

2009-06-24

Objective: Evaluate safety and tolerability of switching from donepezil to rivastigmine transdermal patch in patients with mild to moderate Alzheimer's disease. Methods: Prospective, parallel-group, open-label study to evaluate immediate or delayed switch from 5-10 mg/day donepezil to 4.6 mg/24 h rivastigmine following a 4-week treatment period. Results: Rates of discontinuation due to any reason or adverse events were similar between groups. Incidences of gastrointestinal adverse events were 3.8% in the immediate and 0.8% in the delayed switch group. No patients discontinued secondary to nausea and vomiting. Discontinuations due to application site reactions were low (2.3%). Asymptomatic bradycardia was more common following the immediate switch (2.3% vs 0%); however, these patients had coexisting cardiac comorbidities. Conclusion: Both switch strategies were safe and well tolerated. The majority of patients may be able to switch directly to rivastigmine patches without a withdrawal period. Appropriate clinical judgment should be used for patients with existing bradycardia or receiving β blockers.

News Briefs

2009-06-24