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

Review of Issue: Barriers to Hospice in Patients With Alzheimer

Lippa, C. F. — Wed, 18 Nov 2009 17:03:27 PST

Review: Obesity and Alzheimer's Disease: A Link Between Body Weight and Cognitive Function in Old Age

Naderali, E. K., Ratcliffe, S. H., Dale, M. C. — Wed, 18 Nov 2009 17:03:27 PST

Obesity is now a global health hazard. It not only predisposes to an array of risk factors leading to increased morbidity and mortality amongst adults but it also has a major negative impact on children’s health. The deleterious effects of obesity on cardiovascular system have now been well acknowledged. It causes insulin resistance that in turn leads to diabetes, hypertension and cardiovascular abnormalities. The vascular effects of obesity may have a role in the development of a rapidly growing disease of late life, Alzheimer’s disease. The precise mechanisms of the association between adiposity and impairment of cognitive performance remain to be elucidated. However, negative impact of obesity on cognitive function may be, at least in part, due to vascular defects, impaired insulin metabolism and signaling pathway or a defect in glucose transport mechanisms in brain. This review examines the available data regarding the impact of obesity on cognitive function.

The Effect of Multisensory Stimulation on Persons Residing in an Extended Care Facility

Ward-Smith, P., Llanque, S. M., Curran, D. — Wed, 18 Nov 2009 17:03:27 PST

Background: Non-pharmacological interventions, such as multisensory stimulation environments (MSSE), have demonstrated the ability to reduce inappropriate behavior among individuals with Alzheimer’s disease. Methods: In this study, we compared the incidences of problematic behavior among individuals with Alzheimer’s disease residing in a long-term care facility who were and were not exposed to an MSSE. Retrospective data were obtained using the Psychotic Behavior Assessment Record (PBAR), mandated by Medicare to be used when antipsychotic medications are administered. Psychotic Behavior Assessment Record data were collected using the first and sixth month of admission for residents after appropriate consent was secured. Results: Documented disruptive behavior included pacing, exit-seeking activities, hitting, yelling, and aggressive talking. The use of the MSSE resulted in a decrease in the number of incidences of disruptive behavior, but not the behaviors present. Conclusion: The use of MSSE, as a non-pharmacological intervention, demonstrates the ability to decrease the number of incidences of disruptive or problematic behavior. The use of these interventions, where feasible, should be considered prior to the use of pharmacological methods.

Progranulin and {beta}-Amyloid Distribution: A Case Report of the Brain From Preclinical PS-1 Mutation Carrier

Gliebus, G., Rosso, A., Lippa, C. F. — Wed, 18 Nov 2009 17:03:27 PST

Background: Progranulin (PGRN) is a multifunctional growth factor that is found in many tissues. Mutations in the PGRN gene cause familial frontotemporal dementia with ubiquitin-positive inclusions. PGRN plaque-like structures have been described in Alzheimer’s disease (AD), in association with β-amyloid (Aβ) plaques. Objective: To investigate PGRN and aggregated Aβ immunolabeling distribution in autopsied brain tissue from the participant with confirmed PS-1 (A246E) mutation, who died prior to clinical symptom onset. Results: Immunolabeling for PGRN was positive and accumulated/formed plaque-like structures in all studied regions. These structures most frequently colocalized with Aβ though there were some that did not. PGRN plaques were most dense in medial temporal and frontal regions and predominated over aggregated Aβ. Conclusions: This case report illustrates PGRN accumulation and Aβ aggregation in preclinical PS-1 AD case and raises the question whether this phenomenon coincides with or precedes Aβ aggregation.

Longitudinal Verbal Fluency in Normal Aging, Preclinical, and Prevalent Alzheimer's Disease

Clark, L. J., Gatz, M., Zheng, L., Chen, Y.-L., McCleary, C., Mack, W. J. — Wed, 18 Nov 2009 17:03:27 PST

Background: Few longitudinal studies evaluate differences in patterns of change of category compared to letter fluency across the spectrum of cognitive impairment. Methods: We compared change in category (animal and supermarket) and letter (F, A, S) fluency among 239 participants in 3 groups: remained cognitively normal throughout follow-up (n = 96), developed Alzheimer’s Disease (AD; preclinical AD, n = 21), and with AD at initial testing (prevalent AD, n = 122). Results: At baseline, prevalent and preclinical AD groups scored lower on animal than letter fluency. On all fluency measures, the prevalent AD declined faster than other groups (all P < .0001), and preclinical AD declined faster than unimpaired (all P ≤ .02). Overall, animal fluency declined faster than letter fluency; animal fluency declined significantly faster than letter fluency among cognitively normal and prevalent AD participants. Conclusion: Greater longitudinal declines in category compared to letter fluency are consistent with cross-sectional studies. Steeper declines on both fluency measures distinguish preclinical AD from cognitively unimpaired individuals.

The Role of Caregiver Prosody in Conversations With Persons Who Have Alzheimer's Disease

Small, J. A., Huxtable, A., Walsh, M. — Wed, 18 Nov 2009 17:03:27 PST

This research was supported in part by funding from the British Columbia Medical Services Foundation (BCM02-0115). The funding source had no role in the design, methods, participant recruitment, data collection, interpretation of the study, or in the preparation of the manuscript for publication. Approval for the study was granted by the University of British Columbia Behavioural Ethics Review Board, and participants provided informed consent. This study investigated whether aspects of family caregivers’ prosody (pitch and loudness) would be associated with successful or unsuccessful conversations with spouses who have Alzheimer’s disease (AD). Secondary analysis was conducted of 12 caregivers’ speech when interacting with spouses who have AD. Acoustic analyses were conducted to calculate the fundamental frequency (pitch) and intensity (loudness) of caregivers’ speech. The results showed no significant overall differences between the caregivers’ pitch or loudness in either successful or unsuccessful conversations. However, for 1 subgroup of caregivers, an increase in pitch variation and loudness was associated with unsuccessful communication, whereas for another subgroup the opposite pattern was observed—reduced pitch variation and loudness with unsuccessful communication. The results provide preliminary directions for helping family caregivers become aware of how characteristics of their speech prosody may relate to the quality of communication when interacting with persons who have AD.

Hospice Access for Individuals With Dementia

McCarty, C. E., Volicer, L. — Wed, 18 Nov 2009 17:03:27 PST

Involvement in a hospice program is important because it may allow individuals with dementia to delay or prevent institutionalization as well as provide psychosocial support for their families. Once used mostly by patients with a terminal cancer, now more than one half of the hospice patients have diagnoses other than cancer. Yet hospice is still underused for individuals dying with advanced dementia. We conducted a pilot study of hospice agencies to determine barriers and characteristics of dementia hospice enrollment. Using a mailed questionnaire and interview, we looked at demographics, accessibility, training, referral sources, and marketing. Our analysis divided the agencies based on dementia census and availability to non-Medicare eligible individuals. Results showed hospices having Bridge and Transition programs had on average 4 times higher Alzheimer’s disease (AD) and dementia census than hospices without these programs. The highest rated barriers to hospice use for individuals with dementia were prognosis, education, and finance.

News Briefs

Wed, 18 Nov 2009 17:03:27 PST

Review of Issue: Primary Progressive Aphasia and Caregiver Issues

Lippa, C. F. — Thu, 01 Oct 2009 17:04:51 PDT

Cerebrospinal Immunoglobulin Level Changes and Clinical Response to Treatment of Hashimoto's Encephalopathy

Gliebus, G., Lippa, C. F. — Thu, 01 Oct 2009 17:04:51 PDT

We describe a 64-year-old male who presented with a 2-year history of behavioral and cognitive decline. Brain imaging showed nonenhancing hemispheric white matter lesions. Blood work revealed elevated thyroglobulin and thyroperoxidase antibody levels. Cerebrospinal fluid (CSF) analysis was largely negative, except for an elevated protein and immunoglobulin G (IgG) level. Because of the absence of stroke, central nervous system (CNS) tumor, or infection, this patient fits into criteria of Hashimoto’s encephalopathy. His Mini-Mental State Examination score improved from 10 to 29 after initial immunotherapy. The patient remained stable over 6 months with monthly outpatient total plasma exchange, but symptoms recurred within 3 months when the outpatient therapy was discontinued. A follow-up CSF IgG level was found to be increased and the treatment was repeated with partial clinical improvement and decline in CSF IgG level. He then underwent high dose steroid treatment after which patients’ clinical condition stabilized and CSF analysis showed even further IgG decline.

The Caregiver's Burden of Alzheimer Patients: Differences Between Live-In and Non-Live-In

Raccichini, A., Castellani, S., Civerchia, P., Fioravanti, P., Scarpino, O. — Thu, 01 Oct 2009 17:04:52 PDT

The objective of our study was to describe the burden of a sample of 208 live-in/non-live-in caregivers of patients with Alzheimer’s disease (AD). We analyzed the statistical correlation between Caregiver Burden Inventory (CBI) and the live-in/non-live-in caregiver status, and between the ‘‘objective burden,’’ the cognitive deterioration, functional ability, and psychic and behavioral disorders. Using analysis of variance (ANOVA), the live-in groups of caregivers were compared to each subscale and to the total CBI. Living with a patient causes a bigger burden associated to the ‘‘developmental and physical burden,’’ which is affected more by the functional impairment than by the cognitive-behavioral aspect. Understanding the aspects of this burden in the initial-intermediate phase of the disease and being able to monitor it over time could contribute to improving the interventions already in place, which affect burden, stress, and quality of life of caregivers and their sick family members.

The Effect of Dementia Patient's Physical, Cognitive, and Emotional/ Behavioral Problems on Caregiver Well-Being: Findings From a Spanish-Speaking Sample From Colombia, South America

Arango Lasprilla, J. C., Moreno, A., Rogers, H., Francis, K. — Thu, 01 Oct 2009 17:04:52 PDT

The current study aims to (1) determine whether there is a relationship between the problems of patients with dementia and the psychosocial functioning of the caregiver, (2) determine whether these relationships exist independent of sociodemographic and caregiving-related variables, and (3) determine which type of problems of patients with dementia best predict the psychosocial functioning of the caregiver. In all, 73 family caregivers were recruited from Bogota, Colombia. The caregivers completed a checklist of problems presented by the person with dementia, Patient Health Questionnaire (PHQ-9), Zarit Burden Interview (ZBI), Interpersonal Support Evaluation List (ISEL-12), and Satisfaction with Life Scale (SWLS). Number of cognitive and behavioral/emotional problems presented by the person with dementia was positively correlated with caregiver PHQ-9 and ZBI scores. Number of behavioral/emotional problems was negatively correlated with ISEL-12 scores. Cognitive and behavioral/emotional problems, but not physical, presented by the person with dementia were associated with higher levels of depression and burden of caregiver. Behavioral/emotional difficulties were associated with lower caregiver-perceived social support rating.

Computerized Cognitive Assessment of Mild Cognitive Impairment in Urban African Americans

Doniger, G. M., Jo, M.-Y., Simon, E. S., Crystal, H. A. — Thu, 01 Oct 2009 17:04:52 PDT

Few objective cognitive assessment tools have been validated for mild cognitive impairment (MCI) in African Americans despite higher prevalence of disease. This preliminary study evaluated discriminant validity of a computerized cognitive assessment battery for MCI in an urban African American cohort. Twenty-seven participants with MCI and 22 cognitively healthy individuals completed a multidomain battery (Mindstreams, NeuroTrax Corp, New Jersey). Mild cognitive impairment participants performed more poorly than cognitively healthy participants in all domains, with significant differences in memory (P = .003; d = 0.96), executive function (P = .046; d = 0.64), and overall battery performance (P = .041; d = 0.63). Adjustment for intelligence quotient (IQ) yielded significant differences in memory (P < .001; d = 1.34), executive function (P = .007; d = 0.86), attention (P = .014; d = .80), and overall performance (P = .001; d = 1.09). Such a validated battery may help to address an important clinical need in this population.

Novel PSEN1 Mutation in a Bulgarian Patient With Very Early-Onset Alzheimer's Disease, Spastic Paraparesis, and Extrapyramidal Signs

Thu, 01 Oct 2009 17:04:52 PDT

We describe the phenotype of a Bulgarian early-onset Alzheimer’s disease (EOAD) family with 3 affected patients in 3 generations. In the proband, a novel L381V mutation in the presenilin1 (PSEN1) gene was identified. In this patient, the first symptoms were noticed at the age of 32 years and she died at the age of 37 years. The EOAD phenotype caused by the novel L381V mutation in the PSEN1 gene presented clinically, by a very early onset in the proband, rapid progression of dementia, spastic paraparesis, and extrapyramidal signs, as atypical clinical signs in Alzheimer’s disease patients.

The Northwestern Anagram Test: Measuring Sentence Production in Primary Progressive Aphasia

Thu, 01 Oct 2009 17:04:52 PDT

Primary progressive aphasia (PPA) is a clinical dementia syndrome with early symptoms of language dysfunction. Postmortem findings are varied and include Alzheimer disease and frontotemporal lobar degeneration (FTLD), both tauopathies and TAR DNA binding protein (TDP-43) proteinopathies. Clinical-pathological correlations in PPA are complex but the presence in the clinical profile of agrammatism has a high association with tauopathy. Grammatical competence is difficult to assess in the clinical setting with available methods. This article describes the Northwestern Anagram Test (NAT), a new clinical measure of sentence production. A total of 16 patients with PPA and their controls assembled single printed words to create sentences describing pictures. Northwestern Anagram Test performance was significantly correlated with a measure of sentence production and with aphasia severity but not with measures of naming, single word comprehension, object recognition, or motor speech. The NAT can be used to assess syntax competence when patients cannot be tested with measures that require intact speech production.

Elderspeak's Influence on Resistiveness to Care: Focus on Behavioral Events

Herman, R. E., Williams, K. N. — Thu, 01 Oct 2009 17:04:52 PDT

Resistiveness to care (RTC) in older adults with dementia commonly disrupts nursing care. Research has found that elderspeak (infantilizing communication) use by nursing home (NH) staff increases the probability of RTC in older adults with dementia. The current analysis used general sequential querier (GSEQ) software to analyze behavior sequences of specific behavioral events. We found that older adults with dementia most frequently reacted to elderspeak communication by negative vocalizations (screaming or yelling, negative verbalizations, crying). Because negative vocalizations disrupt nursing care, reduction in elderspeak use by staff may reduce these behaviors thereby increasing the quality of care to these residents. The results clearly demonstrate that sequential analysis of behavioral events is a useful tool in examining complex communicative interactions and targeting specific problem behaviors.

News Briefs

Thu, 01 Oct 2009 17:04:52 PDT

Review of Issue: The Media and Cognitive Health in Our Aging Population

Lippa, C. F. — Tue, 04 Aug 2009 14:14:52 PDT

A Multicenter, Open-Label, 24-Week Follow-Up Study for Efficacy on Cognitive Function of Donepezil in Binswanger-Type Subcortical Vascular Dementia

Tue, 04 Aug 2009 14:14:52 PDT

Objectives: To evaluate the efficacy and tolerability of donepezil in patients with Binswanger type subcortical vascular dementia. Methods: Patients (n = 34, mean age = 71.8 + 7.12) with Binswanger type subcortical vascular dementia from 8 multicenter, according to clinical and neuroradiological working criteria, were selected to receive donepezil 5 mg/day (n = 2) or donepezil 10 mg/day (n = 32, after 5 mg/day) for 24 weeks. Our primary endpoints were change from baseline to weeks 12 and 24 in the Seoul Neuropsychological Screening Battery-Dementia version (SNSB-D) and the Korean version of neuropsychiatric inventory (K-NPI). Results: A total of 24 patients received donepezil completed the study (mean age = 72.0 + 7.5 K-Mini-Mental State Examination [MMSE] = 21.0 + 5.1). After 12 weeks and 24 weeks, patients showed improvements in cognitive function on the SNSB-D compared baseline of 16.29 points at 12 weeks (P < .05) and 12.44 points at 24 weeks (P < .05). Significant improvements were shown in only memory domain, immediate verbal recall and delayed recall tests. Subgroup with better cognitive function (SNSB-D > 100) were more effective in frontal and memory domains than the other subgroup (SNSB-D < 100). Withdrawal rates due to adverse events were very low (4.16%). Conclusions: Donepezil-treated patients with Binswanger type subcortical vascular dementia demonstrated significant improvement in cognition compared with baseline, and donepezil was well tolerated.

What Are The Top-Circulating Magazines in the United States Telling Older Adults About Cognitive Health?

Mathews, A. E., Laditka, S. B., Laditka, J. N., Friedman, D. B. — Tue, 04 Aug 2009 14:14:52 PDT

There is growing evidence that healthy behaviors may promote cognitive health. The behaviors include physical activity, heart-healthy diets, and social engagement. Popular print media helps disseminate health information. This study examines the content focused on cognitive health in 5 top—circulating magazines marketed to older people in the United States. All pages (29 881 pages) of each magazine published in 2006 and 2007 were searched. There were 84 articles on cognitive health. Few were by health or science writers. Of the 58 articles on prevention, the contents focused primarily on diet and multiple behaviors, with less on physical activity or social engagement. Less than 20% provided resources to help readers obtain further information. Articles focused on physical activity, with information directing readers to credible resources, and by writers with health or science backgrounds, could enhance the quality of cognitive health communication in popular media.

Visuospatial Function is a Significant Contributor to Functional Status in Patients With Alzheimer's Disease

Fukui, T., Lee, E. — Tue, 04 Aug 2009 14:14:52 PDT

Background: Contribution of visuospatial abilities to the functional status in patients with Alzheimer’s disease (AD) has been controversial. Aim: To address whether visuospatial abilities have independent association with functional measures in patients with AD. Methods: We regressed performances on a global cognitive (the revised Hasegawa Dementia Scale: HDSR), executive/ visuoconstruction (Clock drawing), visuoperception (Clock reading: CRT), simple visuoconstruction (figure copying), and frontal behavioral tasks on measures of basic and instrumental activities of daily living (BADL and IADL) in 57 patients (78.0 + 6.1 years) with AD of various severity (mean HDSR score: 16.0 + 5.9). We sought independent contributions of these visuospatial measures to functional status. Results: Performance on the CRT contributed significantly to BADL and IADL and the results of HDSR contributed to IADL. Results of figure copying related significantly to BADL especially in mild AD. Conclusion: Visuospatial ability is one of the important contributors to functional status.

Scheduled Medications and Falls in Dementia Patients Utilizing a Wander Garden

Detweiler, M. B., Murphy, P. F., Kim, K. Y., Myers, L. C., Ashai, A. — Tue, 04 Aug 2009 14:14:52 PDT

Little has been reported about the relationship of a dementia wander garden with scheduled psychiatric medications in addition to changes in fall number and severity. The 28 participating residents of a dementia unit were divided into high (HUG) and low (LUG) wander garden user groups and assessed for the number and severity of falls. The type and dose of scheduled psychiatric medications were monitored for 12 months before and 12 months after the wander garden was opened. Results indicated that the residents experienced about a 30% decrease for the raw number of falls and fall severity scores. The HUG had a significant reduction in high-dose antipsychotics, whereas there was relatively no change in antidepressant, hypnotic, and anxiolytic use. High wander garden user group required fewer scheduled medications and experienced reduced falls and lower fall morbidity than the LUG. The most significant changes in scheduled psychiatric medications were reductions in scheduled antipsychotics and an increase in residents requiring no antipsychotics.

Dementia-Friendly Architecture: Environments That Facilitate Wayfinding in Nursing Homes

Marquardt, G., Schmieg, P. — Tue, 04 Aug 2009 14:14:52 PDT

Spatial disorientation is a prime reason for institutionalization. The autonomy of the residents and their quality of life, however, is strongly linked with their ability to reach certain places within their nursing home. The physical environment has a great potential for supporting a resident’s wayfinding abilities. For this study, data were collected from 30 German nursing homes. Skilled nurses rated the resident’s ability to perform 5 wayfinding tasks. The architectural characteristics of the homes were analyzed and their impact on the resulting scores was tested for statistical significance using the Mann-Whitney U test (P < .05). Results confirm that people with advancing dementia are increasingly dependent on a compensating environment. The significant factors include a small number of residents per living area, the straight layout of the circulation system without any changes in direction, and the provision of only 1 living/dining room. These and additional results were transformed into architectural guidelines.

Apathy and Depressive Mood in Nursing Home Patients With Early-Onset Dementia

Leontjevas, R., van Hooren, S., Waterink, W., Mulders, A. — Tue, 04 Aug 2009 14:14:52 PDT

The study explored whether apathy and depressive mood symptoms (DMS) are related to cognitive and functional features of dementia in 63 nursing home (NH) residents with early-onset dementia (EOD). All EOD residents from one NH (n = 41) and a random sample from another NH were assessed for depressive symptoms (Montgomery Asberg Depression Rating Scale [MADRS]), apathy (Neuropsychiatric Inventory [NPI]), global cognitive functions (Mini-Mental State Examination [MMSE]), activities of daily living (ADL, Minimum Data Set—Resident Assessment Instrument [MDS-RAI]), and overall dementia severity (Global Deterioration Scale [GDS]). DMS were not associated with apathy and dementia severity. Regression analyses adjusted for age, gender, the type of dementia, and DMS revealed that dementia severity measures accounted, respectively, for 14% (ADL), 13% (GDS), and 9% (MMSE) of the variance in apathy. In line with previous research in older patients, the higher apathy scores were associated with more cognitive and functional problems in EOD.

ApoE Genotype and Family History in Patients With Dementia and Cognitively Intact Spousal Controls

Zintl, M., Schmitz, G., Hajak, G., Klunemann, H.-H. — Tue, 04 Aug 2009 14:14:52 PDT

Objective: To test that a positive family history and ApoE e4 genotype are prevalent among dementia patients with onset before 70 years of age compared with healthy spousal controls. Methods: A total of 210 patients with dementia and 82 spousal control participants. Neuropsychiatric examination, Consortium to establish a registry on Alzheimer’s disease test battery, Clock-drawing Test, and ApoE genotyping were performed in patients and controls. Results: Of the 131 patients with Alzheimer dementia, 25 were homozygous for Apo e4. Among dementia patients with a positive family history (n = 83), homozygosity for the Apo e4 genotype was found in 19 (22.9%). A positive family history was highest among Apo e4 homozygous Alzheimer dementia patients (72.0%) and lowest among the cognitively normal spousal controls (9.3%). Conclusions: In our sample of patients with Alzheimer dementia, approximately 3 of 4 (72.0%) were homozygous for the genotype Apo e4 when they had a positive family history.

News Briefs

Tue, 04 Aug 2009 14:14:52 PDT

Review of Issue: Strategies for Patient Diagnosis and Management

Lippa, C. F. — Wed, 24 Jun 2009 14:23:34 PDT

Review: Donepezil in Severe Alzheimer's Disease

Winblad, B. — Wed, 24 Jun 2009 14:23:34 PDT

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. — Wed, 24 Jun 2009 14:23:34 PDT

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. — Wed, 24 Jun 2009 14:23:34 PDT

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. — Wed, 24 Jun 2009 14:23:34 PDT

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

Wed, 24 Jun 2009 14:23:34 PDT

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. — Wed, 24 Jun 2009 14:23:34 PDT

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

Wed, 24 Jun 2009 14:23:34 PDT

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

Wed, 24 Jun 2009 14:23:34 PDT

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

Wed, 24 Jun 2009 14:23:34 PDT

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

Wed, 24 Jun 2009 14:23:34 PDT