American Journal of Alzheimer's Disease and Other Dementias recent issues

Review of Issue: Safety, End-of-Life Issues, and Dealing With Sexually Inappropriate Behavior in Dementia Patients

Lippa, C. F. — 2008-10-03

Standardized Note Template Improves Screening of Firearm Access and Driving Among Veterans With Dementia

LoConte, N. K., Gleason, C. E., Gunter-Hunt, G., Carlsson, C. M., Siebers, M. — 2008-10-03

Little is known about screening used in clinical practice to assess driving and firearm safety among patients with dementia. A case-controlled study was performed, including 22 patients with dementia seen in a geriatric evaluation and management clinic and 22 matched patients with dementia seen in a memory assessment clinic. Data about prevalence of firearm use and driving were obtained. In geriatric evaluation and management clinic, 57.9% of patients had dementia, compared with 71.0% in memory assessment clinic, and more patients were diagnosed with Alzheimer dementia in memory assessment clinic (P = .005). In geriatric evaluation and management clinic, 65% of patients had driving screening compared with 100% in memory assessment clinic (P = .07). Four percent in geriatric evaluation and management clinic were screened for firearm access versus 100% in memory assessment clinic (P < .001). In memory assessment clinic, 31.8% had firearms access and 50% were driving. Many patients continued to drive and have access to firearms. The use of templates for the progress note was effective in increasing the screening rate.

Meaning and Practice of Palliative Care for Nursing Home Residents With Dementia at End of Life

Powers, B. A., Watson, N. M. — 2008-10-03

Objective: To describe the meaning and practice of palliative care (PC) for nursing home (NH) residents with dementia at end of life (EOL). Design: Concurrent mixed methods (quantitative retrospective chart review and qualitative field study). Setting: Three NHs with varying approaches to EOL care: in-house non-Medicare hospice, Medicare hospice by outside agency, and Medicare hospice by outside agency plus specialized staff and comfort care unit. Results: Residents' course fluctuated between curative and comfort care, with a noticeable increase in symptoms right before death. Hospice care was short. Most died of complications of dementia. Families found care decisions based on residents' uncertain disease course difficult. Conclusion: The role of PC for NH residents with dementia at EOL is complex and poorly understood. As they are in a residential setting, decisions need to be made about how residents live, as well as how they die, thus balancing quality of living/comfort with disease management.

Neuropsychiatric Impairments as Predictors of Mild Cognitive Impairment, Dementia, and Alzheimer's Disease

Stepaniuk, J., Ritchie, L. J., Tuokko, H. — 2008-10-03

In this study, the relations between cognitive status and neuropsychiatric impairments in nondemented older adults in cross section and over time is examined. Using data from the Canadian Study of Health and Aging (CSHA), a longitudinal, nation-wide study in which data were collected 3 times (ie, CSHA-1, CSHA-2, CSHA-3) at 5-year intervals, individuals were classified with (n = 240) and without (n = 386) cognitive impairment at CSHA-2. Loss of interest, changes in personality and mood, and depression were reported by a knowledgeable informant (ie, family or friends) more frequently for those with cognitive impairment than for those without cognitive impairment. After controlling for initial cognitive status, loss of interest and depression contributed significantly to the prediction of mild cognitive impairment, dementia, and Alzheimer's disease over time. These findings suggest that these neuropsychiatric impairments play significant roles throughout the course of cognitive decline and should be taken into consideration even before cognitive impairment is evident.

One-Year Follow-up Study of Elderly Group-Home Residents With Dementia

Suzuki, M., Kanamori, M., Yasuda, M., Oshiro, H. — 2008-10-03

For the present research, a 1-year follow-up study was conducted on elderly group-home residents with dementia (n = 13). This research compared the cognitive function and behavioral disorders of the elderly group-home residents with dementia with a control group (n = 13) of elderly patients with dementia in a dementia care ward. Thirteen residents of a group home were observed for 1 year, following the establishment of the group home in January 2003. The subjects in the control group were matched for the sex and dementia type of the group-home residents. The present results suggest that cognitive function among elderly group-home residents was maintained in comparison with elderly patients in a dementia ward. In addition, behavioral and psychological symptoms of dementia were not observed in either group. Furthermore, these findings suggest that behavioral disorders significantly improved in the group-home residents because of the incorporation of activities combining basic and instrumental activities of daily living.

Pharmacotherapy for Inappropriate Sexual Behaviors in Dementia: A Systematic Review of Literature

Ozkan, B., Wilkins, K., Muralee, S., Tampi, R. R. — 2008-10-03

The aim of this study is to systematically review the published literature on pharmacotherapy for inappropriate sexual behaviors in dementia. Literature search of the 5 databases (PubMed, MEDLINE, EMBASE, PsychINFO, and COCHRANE collaboration) and the analysis of the data available for the pharmacotherapeutic treatments of inappropriate sexual behaviors in dementia were carried out.There are no published randomized controlled trials of pharmacotherapy for inappropriate sexual behaviors in dementia, but available data from uncontrolled trials, case series, and individual case reports suggest efficacy for antidepressants, antipsychotics, mood stabilizers, hormonal agents, cimetidine, and pindolol for the treatment of these behaviors. Although there are no controlled data for the treatment of inappropriate sexual behaviors in dementia, available data suggest efficacy for some commonly used pharmacotherapeutic agents.

Transitioning Dementia Residents from Assisted Living to Memory Care Units: A Pilot Study

Kelsey, S. G., Laditka, S. B., Laditka, J. N. — 2008-10-03

Our study examined the process of transitioning residents of assisted living facilities (ALFs) who have Alzheimer's disease or a related disorder to memory care units (MCUs). In-depth surveys with 10 ALF administrators in South Carolina were conducted. Grounded theory identified major themes; thematic analysis organized content. Most administrators used a preadmission screening process to assess cognitive status. About half reported that they discussed the possibility of future transfer to another level of care with the family at admission. Most administrators said that their facilities had transfer policies in place; of these, only two-thirds discussed their policies with families on admission. Transfer triggers included leaving the facility without anyone's knowledge, disturbing behaviors, and increased care needs. Challenges included family resistance and greater costs of MCUs. Assisted living facilities that were part of continuing care retirement communities used more multidisciplinary transfer decision-making than free-standing ALFs. Suggested improvements stressed educating families about dementia and MCUs.

Cognitive Deficits and Reduced Insight in Primary Progressive Aphasia

Banks, S. J., Weintraub, S. — 2008-10-03

Primary progressive aphasia (PPA) is a form of dementia caused by frontotemporal lobar degeneration. Unlike aphasia due to stroke, in which the association between particular aphasia profiles and insight has been well characterized, this relationship has not been investigated in PPA. Reduced insight is seen in other neurological conditions, but tends to involve right hemisphere damage, whereas PPA is predominantly a left hemisphere disorder. The aim of the current study was to examine whether fluent aphasia with less meaningful speech output, associated with diminished insight in stroke, is also characteristic of PPA patients with reduced insight. Fourteen PPA patients were studied. Results indicated that reduced information content in speech and poor performance on a nonlanguage test, the Pyramids and Palm Trees test, predicted reduced insight. This study has implications for the anatomical network involved in insight and clinical implications in terms of selecting interventions appropriate for individual patients with PPA.

Multisensory Stimulation for Elderly With Dementia: A 24-Week Single-Blind Randomized Controlled Pilot Study

2008-10-03

Background: Dementia in the elderly is a common, debilitating condition. Residents in long-term care facilities present with a number of challenging behaviors. Pharmacological management is not always helpful. Alternative approaches are needed. Methods: Multisensory stimulation (MSS) was developed to address sensory stimulation imbalance. In this pilot 24-week single-blinded, randomized controlled study, the authors examined the effect of MSS when given for 12 weeks in either 1 or 3 sessions per week with a control group. Results: There is a trend for better outcomes as measured by daily observation scales (DOS) or Clinical Global Impression-Improvement (CGI-I) with the increase of sessions of treatment per week. This became statistically significant at weeks 8 (DOS) and 12 (CGI). This difference continued for 12 additional weeks after treatment ended. Conclusions: MSS may be a useful addition to the care of elderly patients with dementia. A larger double-blind randomized control study is required.

The Clock-Drawing Test: Time for a Change?

Chan, A., Remington, R., Paskavitz, J., Shea, T. B. — 2008-10-03

Clock-drawing tests are simple and rapid screening devices for dementia. It was observed that individuals <60 years of age showed similar performance with a digital prompt (" . . .make the clock read 12:45") or an analog prompt (" . . .quarter to 1"), whereas individuals >70 years of age showed improved performance with an analog prompt. The digital prompt has routinely been used to force participants to recode the prompt via conceptualization. Differential scoring across a range of ages has likely derived from the advent and increase of digital clocks with the younger segment of the population. This implies the need for as-yet undetermined alteration in the nature of prompts to force recoding as the current younger population ages.

The Effects of a Multimodal Intervention on Outcomes of Persons With Early-Stage Dementia

Burgener, S. C., Yang Yang, , Gilbert, R., Marsh-Yant, S. — 2008-10-03

Theories supporting the existence of a use-dependent neuroplasticity in the older brain were used to guide this pilot study. A repeated-measures randomized design was used to test the effectiveness of a multimodal (Taiji exercises, cognitive-behavioral therapies, support group) intervention on cognitive functioning, physical functioning, and behavioral outcomes in persons with dementia. The treatment group (n = 24 persons with dementia) participated in a 40-week intervention, with outcomes assessed at 20 and 40 weeks to assess optimal treatment length. Control group subjects (n = 19 persons with dementia) received attention-control educational programs. At 20 weeks, differences between groups were found for mental ability and self-esteem, with gains in balance being evident. Also, stability in depression and physical health were evident at 20 and 40 weeks for treatment group subjects. Continued improvement in outcomes was not observed at 40 weeks. However, findings support further testing of the intervention along with potential for achieving positive outcomes in early-stage dementia.

News Briefs

2008-10-03

Review of Issue: Studies on Veterans, a Useful Pain Scale, and Plasma Amyloid Levels as a Predictor of Response to Medications

Lippa, C. F. — 2008-06-30

Primary Care Screening for Cognitive Impairment in Elderly Veterans

Donnelly, K., Donnelly, J. P., Cory, E. — 2008-06-30

The objective of this study was to examine the diagnostic accuracy of a primary care screening procedure for identifying cognitive impairment in elderly veterans, in comparison with 4 brief standardized neuropsychological tests. The sample included 100 primary care patients who met age and other criteria requiring screening for cognitive impairment. The results indicated that 3 of the tests significantly discriminated normal from mildly impaired status on the Dementia Rating Scale, but the existing procedure failed to correctly identify any cases in the entire sample. Correct classification rates were near 80% for the Mini-Mental State Exam, Clock Drawing Test, and both Trail Making Test (TMT)-A and TMT-B, with high specificity but variable sensitivity. TMT-B produced good results across eight predictive validity indicators when a cutoff of 3 minutes to completion (1 SD) was used to identify cases. There was no evidence to support the current interview-based screening procedure. Additional research with brief standardized screening is encouraged.

Aggression in Individuals Newly Diagnosed With Dementia

2008-06-30

Aggression is often associated with dementia. In this study, aggression in veterans newly diagnosed with dementia was examined and characterized. Participants were ≥60 years diagnosed with dementia at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, from 2001 to 2004. Aggression was defined as a positive caregiver response to 1 or more of 3 probes from the Ryden Aggression Scale, administered during a telephone screen. Of 1276 contacts, 385 (30%) were eligible and agreed to participate; at initial screening, 75 (19.5%) were aggressive (23 [31%] verbally, 9 [12%] physically, 24 [32%] verbally and physically, and 19 [25%] with unspecified aggression). The surprisingly high prevalence of aggression in individuals newly diagnosed with dementia suggests the potential usefulness of early screening for aggression in this population.

An Educational Intervention to Support Caregivers of Elders With Dementia

Devor, M., Renvall, M. — 2008-06-30

The majority of home-dwelling elders with dementia are cared for by family members or friends. Interventions to support community-based caregivers are needed. A community-based seminar series was provided to 300 self-referred family caregivers with dementia. Participants were surveyed for caregiver burden and overload and perceived competence before and 6 months after the seminars. In all, 88 (29%) of participants completed a 6-month survey. Self-perceived caregiver competence improved (3.9 ± 1.6 to 5.0 ± 0.32, P < .006); a trend toward improvement in caregiver overload, and there was no change in caregiver burden. Caregivers with baseline parameters indicative of higher burden, overload, or lower competence showed improved scores at 6 months. The educational program was effective in improving competence and may have slowed the expected increase in burden associated with caring for those with a progressive dementia. Caregivers with higher burden may be targeted for this type of intervention, as they seemed to benefit the most.

The Progression of Behavior in Dementia: An In-Office Guide for Clinicians

Kilik, L. A., Hopkins, R. W., Day, D., Prince, C. R., Prince, P. N., Rows, C. — 2008-06-30

This article examines the progression of behavioral changes in 200 community living and long term care patients using the Kingston Standardized Behavioral Assessment, a measure of traditional neuropsychiatric behaviors (behavioral and psychological symptoms of dementia) and neuropsychological behaviors. A group of patients diagnosed with probable Alzheimer's disease or mixed dementia (Alzheimer's disease and vascular dementia), was assessed using the Kingston Standardized Behavioral Assessment, ranked by total Kingston Standardized Behavioral Assessment score and were divided into quartile-based groups. The scores revealed changes in behavior patterns across quartiles. Significant behavior change appeared even in quartile one. Lower scores were predominantly associated with neuropsychological behaviors; as scores increased, neuropsychiatric behaviors became equally common. An at-a-glance guide characterizing the patterns of increasing behavioral change is provided for clinicians. Behavioral changes appear both early and throughout dementia; the type and pattern of these emerging behaviors change as the disease progresses. Clinicians can use the typical patterns of behavioral change to identify behavioral impairment in individual patients and anticipate future changes and related care needs.

The Mahoney Pain Scale: Examining Pain and Agitation in Advanced Dementia

Mahoney, A. E. J., Peters, L. — 2008-06-30

Pain and distress are widespread for people with dementia. However, effective pain management is limited by the quality of assessment tools. In this study, the development and trial of the Mahoney Pain Scale, which aims to assess pain in advanced dementia and distinguish it from agitation is described. A total of 112 participants with advanced dementia who experienced either pain, agitation, neither or both were assessed via the Mahoney Pain Scale during a pleasant and aversive activity. The Mahoney Pain Scale demonstrated adequate interrater reliability and internal consistency. As predicted, participants experiencing pain and/or agitation obtained higher Mahoney Pain Scale scores during the aversive activity. Participants also differed with respect to their pattern of scores, and consequently, the Mahoney Pain Scale differentiated pain states from non-pain ones. The clinical impressions of nurses who trialed the tool were favorable; they reported that it seemed accurate and easy to use. Thus, the Mahoney Pain Scale may be useful for assessing pain in dementia.

Consensus Statement on Genetic Research in Dementia

2008-06-30

In this article, the authors describe how the European Dementia Consensus Network developed a consensus on research ethics in dementia, taking into account the questions posed by the era of genetic research and its new research methods. The consensus process started with a Delphi procedure to analyze relevant stakeholders' positions by describing their statements on the possibilities and limitations of research into genetic determinants of Alzheimer disease and to describe and analyze the moral desirability of genetic research on Alzheimer disease. The conclusions drawn from the Delphi procedure fuelled the development of the consensus statement, which is presented in this paper. The consensus statement aims to stimulate ethically acceptable research in the field of dementia and the protection of vulnerable elderly patients with dementia from application of inadequate research methods or designs.

Young Adult Attitudes About Alzheimer's Disease

Lundquist, T. S., Ready, R. E. — 2008-06-30

The current generation of young adults will be greatly affected by Alzheimer's disease(AD), but little is known about their attitudes toward persons with Alzheimer's disease. The current study assessed attitudes about Alzheimer's disease in young adults with varying levels of contact with the disease. It was hypothesized that participants who had a high level of contact with someone with Alzheimer's disease previously, in the form of a close relationship, would report more positive attitudes than participants with a low level of contact or no contact. Results revealed that participants who had a high level of contact with persons with AD were more willing to make personal sacrifices for Alzheimer's disease than those who had no contact. Younger persons may realize a greater need to support persons with Alzheimer's disease if they have been personally affected by the disease through a close relationship.

Antibodies Against GM1 in Demented Patients

2008-06-30

The aim of this study was to evaluate the levels of anti-GM1 in demented patients, correlating them with the type and severity of dementia as well as with the eventually coexistent polyneuropathy. Anti-GM1 concentrations were measured in the sera of 33 demented patients with a male-to-female ratio of 1:2.7 (the mean age was 69.7 years for males and 70.1 years for females). Eighty-two percent of the patients revealed increased values of anti-GM1, but only 18.2% demonstrated polyneuropathies. Fifty-nine percent of the patients suffered from vascular dementia. The most severely demented patients demonstrated a Mini-Mental State Examination score of 5 to 23 out of 30 and revealed the most increased levels of anti-GM1 (>40 EU/mL). The findings of this study are indicative of a possible correlation between the levels of anti-GM1 and the severity of dementia, mainly of the vascular type.

Changes in Dietary or Eating Behavior in Frontotemporal Dementia Versus Alzheimer's Disease

Mendez, M. F., Licht, E. A., Shapira, J. S. — 2008-06-30

Background: Changes in dietary or eating behavior are common in dementia and may help distinguish between different dementing illnesses. Objective: To evaluate and characterize differences in dietary and eating behavior among patients with early frontotemporal dementia (FTD) versus Alzheimer's disease (AD). Methods: This study administered the Food-Related Problems Questionnaire (FRPQ) to caregivers of 16 patients with FTD and 16 comparable patients with AD. The FRPQ was evaluated at initial presentation when patients presented for a diagnostic evaluation. Results: Compared with the AD patients, the FTD patients had significantly more changes on the FRPQ. Subscale analysis indicated that the FTD patients showed impairment of observed satiety, improper taking of food, and inappropriate responses when food was not available. Conclusions: The use of food-related questionnaires, such as the FRPQ, can help distinguish FTD patients, early in their course, from those with AD and can further characterize the altered dietary and eating behavior.

The Clinical Significance of Plasmatic Amyloid A{beta}-40 Peptide Levels in Alzheimer's Disease Patients Treated With Galantamine

Modrego, P. J., Monleon, I., Sarasa, M. — 2008-06-30

To date there are no conclusive reports on the usefulness of determining amyloid peptides in the serum of patients with Alzheimer's disease (AD). Only anecdotal works deal with the changes in the peptides produced by cholinesterase inhibitors. In this study, the authors investigated and studied the clinical significance of plasmatic Aβ-40 and Aβ-42 peptide levels in a series of 34 consecutive patients with AD. The baseline levels of the Aβ-40 peptide correlated negatively with the Mini Examen Cognoscitivo (Spanish version of the Mini-Mental test) score. Complete follow-up was possible in 22 patients. After 6 months of treatment with galantamine, the mean Aβ-40 peptide levels decreased from 31.86 to 24.22 pg/mL. The baseline levels of Aβ-40 were predictive of response to treatment in the Alzheimer's Disease Assessment Scale—Cognitive Subscale. The authors conclude that determining plasmatic Aβ-40 peptide levels could be useful in predicting and monitoring response to treatment in AD.

News Briefs

2008-06-30

Review of Issue: Treatment Strategies, Early Disease Detection, and Insulin Metabolism

Lippa, C. F. — 2008-04-17

Patient Care and Management of Frontotemporal Lobar Degeneration

Massimo, L., Grossman, M. — 2008-04-17

Frontotemporal lobar degeneration (FTLD) is a neurodegenerative disease that affects frontal and temporal regions of the brain. Two proteins indicated in the pathology are tau and the recently discovered TDP-43. Major manifestations include progressive aphasia and a disorder of social comportment. The diagnosis of a patient includes a detailed cognitive exam, clinical testing, and neuroimaging techniques. The current goal of therapy for FTLD is symptomatic management with medications borrowed from other conditions. Nonpharmacologic management such as behavioral interventions and environmental engineering are also efficacious in optimizing quality of life.

A Lifestyle Physical Activity Intervention for Caregivers of Persons With Alzheimer's Disease

2008-04-17

Background: The purpose of this pilot study was to examine the effects of lifestyle physical activity in caregivers (CGs) of persons with Alzheimer's disease. Methods: Fifteen CGs engaged in lifestyle physical activity during a 6-month, home-based health promotion program. Mean changes in self-reported physical activity were compared using repeated-measures analysis of variance. Results: Fifty percent of CGs increased total self-reported minutes and 42% increased total moderate minutes of physical activity from preintervention to postintervention; however, no CG engaged in vigorous physical activity and there were no significant improvements in self-reported physical activity for the total group. Hot summer weather, heavy noncaregiving responsibilities, heavy caregiving responsibilities, and feelings of anxiety, depressive symptoms, and fatigue were the most frequently identified physical activity barriers. Conclusion: Incorporating an individualized, home-based program of lifestyle physical activity appears feasible; however, attention needs to be given in the future to physical activity barriers identified by this select group of CGs.

Psychometric Evaluation of the Shortened Resilience Scale Among Alzheimer's Caregivers

Wilks, S. E. — 2008-04-17

The purpose of this study was to evaluate psychometric properties of the shortened Resilience Scale (15-item version RS15) among a sample of Alzheimer's caregivers. Self-reported data were collected from 229 participants at 2 Alzheimer's caregiver conferences. RS15 principal axis factoring indicated a single-dimensional solution with all items loaded. Reliability was strong. Convergent validity for the RS15 was suggested through its correlations with stress, family suppport, and friend support. Odds ratios showed significant likelihoods of high resilience given low stress and high social support. The results confirmed the RS15 to be a psychometrically sound measure that can be used to appraise the efficacy of adaptability among Alzheimer's caregivers.

Alzheimer's and Non-Alzheimer's Dementia: A Critical Review of Pharmacological and Nonpharmacological Strategies

Saddichha, S., Pandey, V. — 2008-04-17

Objective. Dementia is an age-related progressive neurodegenerative disorder afflicting about 5% of the world's population, and it is expected to grow dramatically in the future keeping in view our ageing society. Currently available medications appear to be able to produce moderate symptomatic benefits but do not to stop disease progression. In this article, the management of the disorder, including the currently available drugs as well as psychosocial strategies, is discussed. Methods. A computerized search on Pubmed from 1980 to 2006 was carried out and all articles evaluated and graded on NICE guidelines. Results and conclusions. Currently evaluated and accepted medications only bring about a reduction in the deteriorating course. A combination of pharmacotherapy and psychosocial management is the need of the hour.

The Japanese MCI Screen for Early Detection of Alzheimer's Disease and Related Disorders

Cho, A., Sugimura, M., Nakano, S., Yamada, T. — 2008-04-17

Early detection of Alzheimer's disease and related disorders in Japan is increasingly important. The Mild Cognitive Impairment Screen (MCIS)—derived from the National Institute of Aging CERAD neuropsychologic battery—differentiates normal aging from MCI and mild dementia with 97.3% and 99% accuracy, respectively. The Japanese MCIS (JMCIS), Mini-Mental State Examination (MMSE), quantitative SPECT (qSP), and quantitative MRI (qMRI) were used to classify 63 outpatients at Fukuoka University Hospital who were either normal or had MCI based on Clinical Dementia Rating scores of 0 and 0.5, respectively. Performance statistics for the JMCIS, MMSE, qSP, and qMRI were, respectively: (1) accuracy = 0.964, 0.768, 0.722, 0.733; (2) sensitivity = 0.958, 0.792, 0.688, 0.700; (3) specificity = 1.000, 0.625, 1.000, 1.000; and (4) validity = 0.813, 0.420, 0.296, 0.308. This initial study shows negligible differences between the English and Japanese MCIS, supporting its potential use for early detection in Japan.

Different Responses to Rivastigmine in Subcortical Vascular Dementia and Multi-Infarct Dementia

Moretti, R., Torre, P., Antonello, R. M., Cazzato, G., Pizzolato, G. — 2008-04-17

Vascular dementia (VaD) is associated with a large amount of heterogeneity, as it groups together a broad category of patients in whom various manifestations of cognitive decline are attributed to cerebrovascular or cardiovascular disease. Thus, a study was designed to determine the effects of rivastigmine on cognitive function, global daily living performance, and behavioral disorders in VaD patients versus an active control (nimodipine), stratifying patients according to the type of VaD, subcortical vascular dementia (sVAD), and multi-infarct dementia (MID). The trial was a prospective study. This study shows that long-term treatment with rivastigmine, at dosages approved for therapeutic use in Alzheimer's disease, produces significant improvement in all behavioral symptoms in 2 forms of VaD, MID and sVaD, except delusions. It also suggests that rivastigmine may enable a reduction in concomitant neuroleptics and benzodiazepines in VaD, especially in MID. The results are discussed with an overview of the literature.

Effects of a Goal-Oriented Rehabilitation Program in Mild Cognitive Impairment: A Pilot Study

Londos, E., Boschian, K., Linden, A., Persson, C., Minthon, L., Lexell, J. — 2008-04-17

Background: Memory disturbance, deficient concentration, and fatigue are symptoms seen in amnestic mild cognitive impairment (MCI) as well as in mild traumatic brain injury (TBI). The aim of this study was to assess if an established rehabilitation program commonly used in TBI can aid MCI patients to develop compensatory memory strategies that can improve their cognition, occupational performance, and quality of life (QoL). Methods: Fifteen patients with MCI participated in the program 2 days per week for 8 weeks. Cognitive function, occupational performance, and self-perceived QoL were assessed at baseline, at the end of the intervention, and at follow-up after 6 months. Results: Significant improvements were seen in cognitive processing speed, occupational performance, and in some of the QoL domains. Conclusion: As this goal-oriented rehabilitation program in MCI resulted in some improvements in cognition, occupational performance, and QoL, further randomized controlled studies are warranted.

Correlative Studies of Structural and Functional Imaging in Primary Progressive Aphasia

Panegyres, P.K., McCarthy, M., Campbell, A., Lenzo, N., Fallon, M., Thompson, J. — 2008-04-17

Rationale: To compare and contrast structural and functional imaging in primary progressive aphasia (PPA). Methods: A cohort of 8 patients diagnosed with PPA presenting with nonfluency were prospectively evaluated. All patients had structural imaging in the form of MRI and in 1 patient CAT scanning on account of a cardiac pacemaker. All patients had single-photon emission computed tomography (SPECT) and positron emission tomography (PET) imaging. Results: SPECT and PET imaging had 100% correlation. Anatomical imaging was abnormal in only 6 of the 8 patients. Wernicke's area showed greater peak Z score reduction and extent of area affected than Broca's area (McNemar paired test: P = .008 for Z score reduction; P = .0003 for extent). PET scanning revealed significant involvement of the anterior cingulum. Conclusion: Functional imaging in PPA: (a) identified more patients correctly than anatomic imaging highlighting the importance of SPECT and PET in the diagnosis; and (b) demonstrated the heterogeneous involvement of disordered linguistic networks in PPA suggesting its syndromic nature.

Role of Insulin Metabolism Disturbances in the Development of Alzheimer Disease: Mini Review

Sabayan, B., Foroughinia, F., Mowla, A., Borhanihaghighi, A. — 2008-04-17

Alzheimer disease (AD) is the most common form of dementia. Different pathogenic processes have been studied that underlie characteristic changes of AD, including Aβ protein aggregation, tau phosphorylation, neurovascular dysfunction, and inflammatory processes. Insulin exerts pleiotropic effects in neurons, such as the regulation of neural proliferation, apoptosis, and synaptic transmission. In this setting, any disturbance in the metabolism of insulin in the central nervous system (CNS) may put unfavorable effects on CNS function. It seems that disturbances in insulin metabolism, especially insulin resistance, play a role in most pathogenic processes that promote the development of AD. In this article, the relationships of disturbances in the metabolism of insulin in CNS with Aβ peptides aggregation, tau protein phosphorylation, inflammatory markers, neuron apoptosis, neurovascular dysfunction, and neurotransmitter modulation are discussed, and future research directions are provided.

Temporal Patterns of Movements in Institutionalized Elderly With Dementia During 12 Consecutive Days of Observation in Seoul, Korea

Makimoto, K., Eun Ah Lee, , Kang, Y., Yamakawa, M., Ashida, N., Kyung Rim Shin, — 2008-04-17

Background: The availability of increasingly sophisticated technology has meant that ambulation can be measured with precision over an extended period. Methods: An integrated circuit tag-monitoring system was set up to measure the distance moved in a dementia care unit in Korea in 2006. Various indicators were developed to measure temporal patterns of ambulation over time, such as the median distance moved per hour and the percentage of hours moved. Results: 12 consecutive days of movement data were available for 8 subjects. The mean age of the subjects was 76 ± 5.3 years. The median distance walked per day ranged from 206 to 976 m, and the percentage of hours with movement ranged from 28% to 81%. The changes in the activity level during daytime, evening, and nighttime also differed among the 8 subjects. Discussion: The indicators developed appeared to differentiate temporal patterns of movement in demented persons.

Review of Issue: Management Strategies, Medical Issues, and Pathobiology

Lippa, R. L. — 2008-02-14

Nutrition Education Needs and Resources for Dementia Care in the Community

2008-02-14

Nutrition problems and specificly weight loss are common in older adults with dementia living in the community. Study 1 involved interviews with 14 formal providers to identify the range of nutrition concerns they had experienced. In study 2, 74 Canadian Alzheimer Society chapters were surveyed by e-mail (23% participation rate) to determine nutrition concerns and education resources provided to clients. In all, 26 of these nutrition pamphlets or handouts were rated on content and format by 2 independent researchers using a standardized rating system. Common nutrition concerns identified in older adults with dementia living in the community include safety, weight loss, forgetting or refusing to eat, appetite, dysphagia, and unfavorable eating behaviors. Most resources provided to clients were considered low quality and did not match the nutrition concerns expressed by formal providers. Currently, there is a considerable knowledge translation gap around nutrition and dementia, and this study provides a basis for the future development of nutrition education resources.

Decision-Making Involvement Scale for Individuals With Dementia and Family Caregivers

Menne, H. L., Tucke, S. S., Whitlatch, C. J., Feinberg, L. F. — 2008-02-14

This report describes the development and preliminary psychometric properties of the Decision-Making Involvement Scale for individuals with dementia and family caregivers. Data were collected from 217 individuals with dementia and their respective caregivers. Principal axis factor analysis, Kendall , and Pearson correlations were used to determine the Decision-Making Involvement Scale's psychometric properties, mean differences of caregiver and individual with dementia, and the relationship between scores of Decision-Making Involvement Scale and measures of well-being. Analyses support a reliable, 1-factor solution of the Decision-Making Involvement Scale for both individuals with dementia and caregivers. Socio-demographic, impairment, and well-being variables are differentially related to the perceptions of how involved the individual with dementia is in decision making. The Decision-Making Involvement Scale provides useful information about daily decision making of an individual with dementia, and it shows promise as a means for understanding the relationship between decision-making involvement and well-being of individuals with dementia and caregivers.

Does a Wander Garden Influence Inappropriate Behaviors in Dementia Residents?

Detweiler, M. B., Murphy, P. F., Myers, L. C., Kim, K. Y. — 2008-02-14

Background: The effect on resident behaviors of adding a wander garden to an existing dementia facility was investigated. Methods: 34 male residents were observed for 12 months before and after opening the garden. Behaviors were assessed using the Cohen-Mansfield Agitation Inventory Short Form (CMAI), incident reports, as needed medications (pro re nata [PRN]), and surveys of staff and residents' family members as indices of affect. Results: Final CMAI scores and total PRNs employed were lower than baseline values with a trend for residents who used the garden more often to have less agitated behavior. Verbal inappropriate behaviors did not change significantly whereas physical incidents increased. Staff and family members felt that the wander garden decreased inappropriate behaviors and improved mood and quality of life of the dementia residents. Conclusions: Study design characteristics and garden management may have affected behaviors both positively and negatively. Additional studies are needed to explore the benefits of wander gardens for dementia residents.

Errorless-Based Techniques Can Improve Route Finding in Early Alzheimer's Disease: A Case Study

Provencher, V., Bier, N., Audet, T., Gagnon, L. — 2008-02-14

Topographical disorientation is a common and early manifestation of dementia of Alzheimer type, which threatens independence in activities of daily living. Errorless-based techniques appear to be effective in helping patients with amnesia to learn routes, but little is known about their effectiveness in early dementia of Alzheimer type. A 77-year-old woman with dementia of Alzheimer type had difficulty in finding her way around her seniors residence, which reduced her social activities. This study used an ABA design (A is the baseline and B is the intervention) with multiple baselines across routes for going to the rosary (target), laundry, and game rooms (controls). The errorless-based technique intervention was applied to 2 of the 3 routes. Analyses showed significant improvement only for the routes learned with errorless-based techniques. Following the study, the participant increased her topographical knowledge of her surroundings. Route learning interventions based on errorless-based techniques appear to be a promising approach for improving the independence in early dementia of Alzheimer type.

Nursing Home Characteristics Related to Medicare Costs for Residents With and Without Dementia

2008-02-14

Objectives. To evaluate the relationship of nursing home characteristics to Medicare costs overall and by dementia status. Design. New admissions followed for 2 years. Setting. Random stratified sample of 55 Maryland nursing homes. Participants. Sample of 1257 residents. Measures. Records, interview, and observation. Results. Medicare costs were lower in facilities that have a better environmental quality, hospice beds, and more food service workers; costs were higher in hospital-based facilities and those that have a higher Medicaid case mix, X-ray, and some specified types of staff. Across all characteristics, costs for residents with dementia were consistently two-thirds the cost of other residents. Discussion. In terms of dementia status, resident characteristics drive Medicare costs, as opposed to facility characteristics. Using alternative residential settings for individuals with dementia may increase Medicare costs of nursing home residents and Medicare costs of residents with dementia who are cared for in settings less able to attend to medical needs.

The Prevalence of Dementia in an Urban Turkish Population

2008-02-14

A cross-sectional, population-based, 2-stage prevalence study was conducted in a sample of 1019 community-dwelling persons over the age of 70 years living in Istanbul. In the first phase, participants were screened with the Mini-Mental State Examination for evidence of cognitive impairment. In the second phase, 79% of those who screened positive (n = 322) and 9% of screen-negatives (n = 63) underwent a standardized diagnostic workup. Diagnosis of dementia and Alzheimer's disease (AD) was made according to established criteria. Ninety-three cases of dementia were identified, 58 of whom were diagnosed with probable AD. Based on these numbers, the prevalence rates of probable AD and dementia were calculated to be 11.0% (95% CI, 7.0% to 15.0%) and 20.0% (95% CI, 14.0% to 26.0%), respectively, in this population. Prevalence rates of dementia and AD in Istanbul, Turkey, are comparable with those seen in the Western world.

Angiotensin Converting Enzyme Inhibitors and Cognitive and Functional Decline in Patients with Alzheimer's Disease: An Observational Study

Hajjar, I. M., Keown, M., Lewis, P., Almor, A. — 2008-02-14

We previously reported that angiotensin converting enzyme inhibitors (ACEIs) decrease the rate of cognitive decline in elderly patients with hypertension, but their impact on patients with Alzheimer's disease (AD) is not known. A total of 62 elderly patients with AD were enrolled, and 52 completed the study for 6 months. Mini-Mental Status Examination (MMSE), Clock Draw Test (CDT), working memory (Digit Ordering), Instrumental Activities of Daily Living (IADL) scale, and the Screen for Caregiver Burden (SCB) were collected at baseline, 3 months, and 6 months. AD patients receiving ACEI (N = 15) demonstrated a slower rate of decline in digit forward (P = .003) and IADL scale (P = .003) and an improved measure of caregiver burden (P = .04) but not MMSE (P =.15) or CDT (P =.9) compared with those not receiving ACEI after adjusting for other risk factors. This study suggests that use of ACEI in AD patients is associated with slower rate of AD progression. A randomized clinical trial is needed to confirm our finding.

Serum Albumin Levels Predict Cognitive Impairment in Elderly Hip Fracture Patients

Mizrahi, E. H., Blumstein, T., Arad, M., Adunsky, A. — 2008-02-14

The aim of this study was to investigate the possible interrelation of serum albumin levels and cognitive function of elderly hip fracture patients. The study involved 331 elderly patients with hip fractures, admitted for rehabilitation. Cognition was assessed by Mini-Mental State Examination (MMSE). MMSE scores less than 24 points were considered suggestive of cognitive impairment. Age, serum albumin levels, and previous stroke emerged as the only statistically significant parameters differing between those with MMSE score less than 24 or higher. After adjusting for confounding variables, the middle and lowest tertiles of serum albumin levels were associated with an increased risk of cognitive impairment (odds ratio 1.97, 95% confidence interval 1.15-3.38, P < .01 vs 3.06 and 1.79-5.23, P < .001, respectively). This study shows that lower serum albumin levels are independently associated with lower MMSE scores in hip fractured elderly patients, supporting the possible role of chronic low-grade inflammation in age-related cognitive decline.

The Cerebrovascular Pathology in Alzheimer's Disease and Its Influence on Clinical Variables

2008-02-14

Vascular pathology is frequently found in the brains of patients with Alzheimer's disease (AD). The aim of this study is to assess the frequency of vascular pathology in the brain in AD patients in a systematic manner and its clinical significance at presentation. A series of 51 patients with mild to moderate AD were consecutively enrolled. At baseline, every patient underwent the following clinical scales: Mini-Mental, Clinical Dementia Rating Scale, Ischemic Scale, Blessed Dementia Rating Scale, Alzheimer's Disease Assessment Scale Cognitive Subscale, Neuropsychiatric Inventory, and an Activities of Daily Living Scale (Disability Assessment for Dementia). We also carried out magnetic resonance imaging of the brain and color echo Doppler of carotids to measure the intima-media thickness. White matter hyperintensities were quantitatively evaluated with the Wahlund scale. We did not find correlation between intima-media thicknesses of carotids and clinical scales and between the Wahlund scale and clinical scales. The presence or absence of both microinfarctions and hypertension had no influence in the scores of the clinical scales. We conclude that the vascular component is common in AD but only as coincident pathology.

Neuritic Pathology as a Correlate of Synaptic Loss in Dementia With Lewy Bodies

Revuelta, G. J., Rosso, A., Lippa, C. F. — 2008-02-14

Synaptic loss is present in Alzheimer's disease and correlates with the severity of dementia. Loss of synapses in dementia with Lewy bodies (DLB) does not correlate as clearly with cognitive status and its cause is unclear. To begin to understand the relationship between cognition and synaptic loss in DLB, we assessed immunoreactivity for the synaptic-terminal specific protein, synaptophysin, in the hippocampus in 14 DLB cases. Quantitative synaptic data were obtained using an Image-Pro semiautomated analysis system. We determined Braak stage, β-amyloid, Lewy bodies (LBs), and Lewy neurites (LN). We found significant correlations (r = 0.617, P < .01) between Braak stage and synaptophysin score and marginal correlation between LN score and synaptophysin loss ( r = 0.694, P < .06). Correlations of β-amyloid and of LB density with synaptophysin score were unimpressive. These data support the hypothesis that synaptic loss in DLB is related to neuritic degeneration.

News Briefs

2008-02-14