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Cures for the various diseases that give rise to dementia remain elusive and are likely to remain so for the foreseeable future. Our current capacity to slow disease progression or to manage symptoms is far from satisfactory. Pharmacological interventions have made only a modest impact to date, and carry risks as well as possible benefits (Ritchie, 2007)
Background: The social and economic burden of Alzheimer's disease (AD) and its increasing prevalence has led to much work on new treatment strategies and clinical trials. The search for surrogate markers of disease progression continues but traditional parallel group trial designs that use well-established, but often insensitive, clinical outcome measures predominate.
Methods: We performed a systematic search across the Cochrane Library and PubMed abstracts published between January 2004 and August 2009. Information regarding the clinical trial methodology, outcome measures, intervention type and primary statistical analysis techniques was extracted and categorized, according to a standard protocol.
Results: We identified 149 papers describing results from clinical trials in AD containing sufficient detail for our purposes. The largest proportion (38%) presented results of trials based on tests of cognition as the primary outcome measure. The primary analysis in most papers (85%) was a univariate significance test of a single primary outcome measure.
Conclusions: The majority of trials reported a comparison of baseline and end-point assessment over relatively short patient follow-up periods, using univariate statistical methods to compare differences between intervention and control groups in the primary analysis. There is considerable scope to introduce newer statistical methods and trial designs in treatment evaluations in AD.
Background: In randomized clinical trials, adverse events (AEs) are reported for the drug under evaluation and compared with the placebo group. Patients who receive placebo treatment report a high frequency of AEs, but little is understood about the nature of these. No study has yet analyzed the level of cognitive impairment as a crucial aspect for the AEs reported by patients.
Methods: The rates of AEs reported by patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD) in the placebo arms of donepezil trials were compared using a systematic review approach. PubMed was searched with the terms “MCI and donepezil” as well as “AD and donepezil” from January 1989 to December 2010. Nineteen studies fulfilled the selection criteria (3 MCI, n = 783; 16 AD, n = 2,059).
Results: An overall comparison of 81 categories of AEs in the placebo arm of MCI versus AD trials showed that patients in AD trials experienced a significantly higher number of AEs than patients in MCI trials (p < 0.001).
Conclusions: This is the first study showing that AD patients may be at a greater risk of developing AEs than MCI patients. This may be related to a greater presence of somatic comorbidity predisposing them to express emotional distress as physical symptoms and/or to AD patients being frailer and therefore more susceptible to AEs. The phenomena we observed may be interpreted in terms of the “nocebo effect”.
Background: Quality of life (QoL) in dementia is a complex construct and factors that predict QoL ratings are unclear. We designed this study to determine: (1) the agreement in QoL ratings between community-dwelling patients with mild to moderate dementia and family carers; and (2) the factors associated with self-reported and two types of carer-reported QoL ratings: carer–carer perspective and carer–patient perspective.
Methods: A cross-sectional study was carried out of 80 community-dwelling patients with the diagnosis of probable Alzheimer's disease (AD) of mild or moderate severity according to NINCDS-ADRD criteria, and their 80 family carers. The QoL-AD was the primary outcome measure. We collected patients’ self-reported QoL ratings and two types of carer-reported QoL ratings: carer–patient and carer–carer perspectives. Explanatory variables included demographics, lifestyle, and clinical information from patients and carers, along with cognition, awareness, psychopathology, burden-of-care, and functionality in daily life. Bland-Altman plots guided the interpretation of agreement by visualizing the distribution of all the ratings. Univariate and multivariate regression analyses were conducted to examine the contribution of candidate explanatory factors.
Results: Patients and their carers showed good agreement in their QoL ratings, although the total scores of carers (regardless of perspective) were lower than the scores of patients. Depression, insight and use of anti-dementia agents were associated with QoL self-ratings, whereas cognitive function was directly associated and depression inversely associated with carers’ QoL ratings.
Conclusion: Mild to moderate community-dwelling AD patients and their carers (with different perspectives) agree within an acceptable range in QoL ratings but the ratings are driven by different factors, and consequently are not interchangeable but complementary. They provide valuable information when used separately, not in a composite score.
Background: Nursing home care for people with dementia is increasingly organized in small-scale care settings. This study focuses on the question of how small-scale care is related to the overall activity involvement of residents with dementia, and their involvement in different types of activities. As several studies have indicated, activity involvement is important for the quality of life of residents.
Methods: Data were derived from the first measurement cycle (2008/2009) of the Living Arrangements for people with Dementia study, in which 136 care facilities and 1,327 residents participated. The relationship between two indicators of small-scale dementia care (group living home care characteristics, and the total number of residents with dementia in the facility) and activity involvement (Activity Pursuit Patterns of the Resident Assessment Instrument Minimum Data Set) were studied with multilevel multiple regression analyses. All analyses were adjusted for the residents' age, sex, neuropsychiatric symptoms, and dependency on the activities of daily living.
Results: Residents of care facilities with more group living home care characteristics were more involved in overall and preferred activities. Furthermore, they were involved in more diverse activities. Overall, no relationship was found between the number of residents at the facility and activity involvement.
Conclusions: These results indicate that small-scale dementia care has a positive effect on activity involvement of residents. The current study also sheds light on the lack of activity involvement of many residents with dementia, especially those who are older, male, and with higher dependency.
Background: Older migrants with dementia and limited English language proficiency in residential care may have unmet needs for social interaction. This project compared verbal communication and prescribed psychiatric medication of Greek and Italian residents with dementia in ethno-specific and mainstream residential care.
Methods: Participants were 82 older Australians of Greek or Italian background who had been diagnosed with dementia and were residing in mainstream or ethno-specific care. Residents were observed and their language use was recorded. An assessment of cognitive impairment was conducted. A structured interview was held with a family member and a staff member.
Results: The observed rate of resident-to-resident communication was higher in the ethno-specific facilities. Staff-to-resident interaction rate did not differ between the facility types. Residents in ethno-specific care were prescribed antipsychotics at a significantly lower rate.
Conclusions: Residents with dementia and limited English language proficiency in mainstream care would benefit from greater opportunities to interact with peers in their own language. Prescribed medication should be monitored to ensure that these residents are not misinterpreted as “disruptive,” or are not actually more agitated due to difficulty in communicating their needs.
Background: Affect, behavior, and cognition can be considered as basic constructs that dictate human functioning, with intricate and bi-directional relationships among them. Prior to the present study, relationships among these constructs have not been systematically examined within the context of dementia.
Methods: Sample 1 contained 185 nursing home residents with a diagnosis of dementia. Sample 2 contained 117 residents with dementia, all of whom manifested agitated behaviors. Outcome measures included stimulus engagement (assessed via the Observational Measure of Engagement), affect (measured using Lawton's Modified Behavior Stream), and agitation/problem behavior (recorded via the Agitated Behaviors Mapping Instrument). Real time direct observations were collected during both stimulus presentation and control conditions.
Results: The relationship of engagement with positive affect, represented by the variables of interest and pleasure, were high and positive. No relationship emerged for engagement with negative affect or agitated behavior. A consistent positive relationship was found between agitated behavior and negative affect, and in Sample 2, a negative relationship between agitated behavior and both pleasure and interest.
Conclusion: This is the first study to examine relationships among variables that are typically examined individually and, in doing so, has clarified the nomenclature used to describe the constructs of affect, engagement, and agitated behaviors in persons with dementia. The finding that the constructs of engagement, agitated behavior, and affect are multidimensional and that relationships among these constructs occur for some of the dimensions is important for the development of interventions and for clear communication in practice and research.
Background: Disruptive behaviors are frequent and often the first predictor of institutionalization. The goal of this multi-center study was to explore the perceptions of family and staff members on the potential contribution of environmental factors that influence disruptive behaviors and quality of life of residents with dementia living in long-term care homes.
Methods: Data were collected using 15 nominal focus groups with 45 family and 59 staff members from eight care units. Groups discussed and created lists of factors that could either reduce disruptive behaviors and facilitate quality of life or encourage disruptive behaviors and impede the quality of life of residents. Then each participant individually selected the nine most important facilitators and obstacles. Themes were identified from the lists of data and operational categories and definitions were developed for independent coding by four researchers.
Results: Participants from both family and staff nominal focus groups highlighted facility, staffing, and resident factors to consider when creating optimal environments. Human environments were perceived to be more important than physical environments and flexibility was judged to be essential. Noise was identified as one of the most important factors influencing behavior and quality of life of residents.
Conclusion: Specialized physical design features can be useful for maintaining quality of life and reducing disruptive behaviors, but they are not sufficient. Although they can ease some of the anxieties and set the stage for social interactions, individuals who make up the human environment are just as important in promoting well-being among residents.
Background: The aim of this study was to compare the screening value of the Mini-Cog, Clock Drawing Test (CDT), Mini-Mental State Examination (MMSE) and the algorithm MMSE and/or CDT to separate elderly people with dementia from healthy depending on test time, type and severity of dementia, and demographic variables in a German Memory Clinic.
Methods: Data from a heterogeneous patient sample and healthy participants (n = 502) were retrospectively analyzed. Of the 438 patients with dementia, 49.1% of the dementia diagnoses were Alzheimer's dementia and 50.9% were non-Alzheimer's dementia. Sixty-four participants were classified as cognitively unimpaired. The CDT and an extraction of the 3-item recall of the MMSE were used to constitute the Mini-Cog algorithm.
Results: Overall, the Mini-Cog showed significantly higher discriminatory power (86.8%) than the MMSE (72.6% at a cut-off ≤ 24 and 79.2% at ≤ 25, respectively) and CDT (78.1%) (each p < 0.01) and did not perform worse than the algorithm MMSE and/or CDT (each p > 0.05). The specificity of the Mini-Cog (100.0%) was similar to that of the MMSE (100.0% for both cut-offs) and CDT (96.9%) (p = 0.154). For all age and educational groups the Mini-Cog outmatched the CDT and MMSE, and was less affected by education than MMSE and less susceptible for the dementia stage than the CDT.
Conclusion: The Mini-Cog proved to have superior discriminatory power than either CDT or MMSE and is demonstrated to be a valid “short” screening instrument taking 3 to 4 minutes to administer in the geriatric setting.
Background: Hospitalized frail older patients are usually assessed for their ability to perform some daily living activities in a clinical setting prior to discharge. However, assessments that take place in this unfamiliar environment might not be as representative of their functional performance as assessments at home. This may be related to a decline in some cognitive components, such as executive functions (EF), which enable one to cope with new environments. This study thus aims to compare cooking task performance in familiar and unfamiliar settings in a population of frail older adults with poor and preserved EF.
Methods: Thirty-seven frail older adults were assigned to one of two groups: poor EF or preserved EF. Participants performed two cooking tasks in familiar and unfamiliar settings, using a counterbalanced design. Their performance was assessed with a reliable tool based on observation of motor and process skills (Assessment of Motor and Process Skills).
Results: Thirty-three participants were retained for analysis. They demonstrated significantly better motor skills (F = 5.536; p = 0.025) and process skills (F = 8.149; p = 0.008) in the familiar setting. The difference between settings was particularly marked for process skills in participants with poor EF (F = 16.920; p < 0.001).
Conclusions: This study suggests that a home setting may be preferable for a more accurate assessment of cooking task performance in frail older adults, especially those with poor EF. These findings highlight the risk of underestimating frail older adults’ performance when assessed in an unfamiliar setting (e.g. hospital), which could lead to inefficient allocation of home care services.
Background: Studies on functional capacity in community-dwelling older people have shown associations between declines in instrumental activities of daily living (IADL) and several factors. Among these, age has been the most consistently related to functional capacity independent of other variables. We aimed at evaluating the performance of a sample of healthy and cognitively intact Brazilian older people on activities of daily living and to analyze its relation to social-demographic variables.
Methods: We conducted a secondary analysis of data collected for previous epidemiological studies with community-dwelling subjects aged 60 years or more. We selected subjects who did not have dementia or depression, and with no history of neurological diseases, heart attack, HIV, hepatitis or arthritis (n = 1,111). Functional capacity was assessed using the Brazilian version of the Older American Resources and Services Questionnaire (BOMFAQ). ADL performance was analyzed according to age, gender, education, and marital status (Pearson's χ2, logistic regression).
Results: IADL difficulties were present in our sample, especially in subjects aged 80 years or more, with lower levels of education, or widowed. The logistic regression analysis results indicated that “higher age” and “lower education” (p ≤ 0.001) remained significantly associated with IADL difficulty.
Conclusions: Functional decline was present in older subjects even in the absence of medical conditions and cognitive impairment. Clinicians and researchers could benefit from knowing what to expect from older people regarding IADL performance in the absence of medical conditions.
Background: This study explored the transport and lifestyle issues of older retired and retiring drivers participating in the University of Queensland Driver Retirement Initiative (UQDRIVE), a group program to promote adjustment to driving cessation for retired and retiring older drivers.
Methods: A mixed method research design explored the impact of UQDRIVE on the transport and lifestyle issues of 55 participants who were of mean age 77.9 years and predominantly female (n = 40). The participants included retired (n = 32) and retiring (n = 23) drivers. Transport and lifestyle issues were identified using the Canadian Occupational Performance Measure and rated pre- and post-intervention.
Results: Paired t-tests demonstrated a statistically significant improvement in performance (t = 10.5, p < 0.001) and satisfaction (t = 9.9, p < 0.001) scores of individual issues. Qualitative content analysis identified three categories of issues including: protecting my lifestyle; a better understanding of transport options; and being prepared and feeling okay.
Conclusions: Participation in UQDRIVE had a positive and significant effect on the issues of the participants. The results highlight that although all participants stated issues related predominantly to practical concerns, there were trends in the issues identified by the drivers and retired drivers that were consistent with their current phase of the driving cessation process.
Background: Training, practice, and continuing professional development in old age psychiatry varies across Europe. The aims of this study were to survey current practice and develop recommendations to begin a debate on harmonization.
Methods: A survey was sent out to 38 European countries via email. The survey was sent to members of the European Association of Geriatric Psychiatry (EAGP) Board, members of the World Psychiatric Association, and key old age psychiatrists or other psychiatrists with a special interest in the area for countries where old age psychiatry was not formally a specialty.
Results: Through a process of networking, we identified a key individual from each country in Europe to participate in this study, and 30 out of 38 (79%) representatives responded. Training programs and duration varied between countries. Eleven countries reported that they had geriatric psychiatry training programs and most of these required geriatric psychiatry trainees to complete mandatory training for two years within old age psychiatry. Representatives from ten countries reported having specific Continuing Professional Development (CPD) for old age psychiatrists at consultant level.
Conclusion: There is a clear indication that the recognition of geriatric psychiatry as a specialist discipline in Europe is on the rise. The training procedures and processes in place vary considerably between and sometimes within countries. There are several options for harmonizing old age psychiatry training across Europe with advantages to each. However, support is required from national old age psychiatry bodies across Europe and an agreement needs to be reached on a training strategy that encompasses supervision, development, and appraisal of the knowledge and skills sets of old age psychiatrists.
Background: Accuracy of estimation of time-intervals has received marginal attention in psychogeriatrics. We examined presumed differences in this time measure in participants with dementia (PWD) versus participants without dementia (PWoutD), further subdivided into specific diagnoses and performance subgroups. We also studied its demographic, clinical, and cognitive correlates and predictors. A diagnostic role was hypothesized.
Methods: Forty-three individuals (27 PWD: 16 dementia of the Alzheimer's type (DAT), 11 vascular dementia (VaD); 16 PWoutD: 10 major depressive disorder (MDD), 6 normal) were interviewed with the Cambridge Examination for Mental Disorders of the Elderly – Revised (CAMDEX-R) that permits the registration of this time measure. Demographic, clinical, and cognitive data were obtained.
Results: Neither absolute accuracy of estimation of duration of interview nor its transformed logarithm were significantly different between PWD and PWoutD, or between DAT and VaD participants. MDD participants performed significantly poorer than normal and did not differ from PWD, and the PWD relatively better performing subgroup. The logarithm of absolute accuracy of estimation correlated with some clinical and cognitive variables. Only a measure of depression and of impaired judgment could significantly predict it.
Conclusions: The absolute accuracy of estimation of time-intervals did not differ between the major groups and the main diagnoses subgroups. It was associated with a variety of clinical and cognitive measures, and was predicted by the composite constructs of depression and impaired judgment. The diagnostic value of this measure in the psychogeriatric clinic is questionable, and limited to “worried” well individuals.
Background: The ways in which aging affects social economic decision-making is a central issue in the psychology of aging. To examine age-related differences in social economic decision-making as a function of empathy, 80 healthy volunteers participated in the Repeated Fixed Opponent Ultimatum Game (UG-R). Previous economic decision-making research has shown that in younger adults empathy is associated with prosocial behavior. The effects of empathy on older adult social economic decision-making are not well understood.
Methods: On each of 20 consecutive trials in the UG-R, one player (“Proposer”) splits $10 with another player (“Responder”) who chooses either to accept (whereby both receive the proposed division) or reject (whereby neither receives anything). Trait cognitive and emotional empathy were measured using the Interpersonal Reactivity Index.
Results: UG-R data were examined as a function of age and cognitive empathy. For “unfair” offers (i.e. offers less than $5), older Responders with high cognitive empathy showed less prosocial behavior and obtained greater payoffs than younger Responders with high cognitive empathy.
Conclusions: High levels of cognitive empathy may differentially affect economic decision-making behavior in younger and older adults. For older adults, high cognitive empathy may play a role in obtaining high financial payoffs while for younger adults it may instead be involved in facilitating social relationships.
Background: Paratonia causes severe movement dysfunction in late stage dementia. Passive Movement Therapy (PMT) is often used to decrease high muscle tone, but the efficacy has never been shown. The objective of this study is to investigate the effect of PMT on muscle tone after two and four weeks of treatment.
Methods: This study comprised a multicenter single-blinded RCT. Nursing home residents with dementia (according to the DSM-IV-TR criteria) and moderate to severe paratonia were randomly assigned to either a PMT or control group. The PMT group received PMT three times a week over four weeks. The control group received no PMT. The primary outcome was the severity of paratonia as measured by the Modified Ashworth scale (MAS). Secondary outcomes were clinical change (Clinical Global Impression; CGI), caregiver's burden (modified patient specific complaints; PSC), and level of pain during morning care (Pain Assessment Checklist for Elderly with Limited Ability to Communicate, Dutch version; PACSLAC-D). All outcomes were assessed at baseline and after two and four weeks. The MAS, PACSLAC-D, and PSC data were subjected to multilevel mixed linear analysis, and the CGI data to cross-tabulation χ2 analysis.
Results: One-hundred-and-one patients from 12 Dutch nursing homes participated in the study; data from 47 patients in the PME group and 54 controls were analyzed. Patients receiving PMT performed no better in paratonia assessments, nor on CGI, PSC, or PACSLAC-D, than controls in two and four week's time.
Conclusion: PMT has no beneficial effects and should therefore not be recommended as an intervention in severe paratonia.
Trial registration: Current Controlled Trials ISRCTN43069940
Antidepressant treatments, including selective serotonin reuptake inhibitors, are associated in older adults with an increased risk of adverse effects compared to younger adults. This is partly explained by multiple drug use causing drug–drug interactions. In the present report, we describe a case of serotonin syndrome in an 88-year-old woman receiving a low dose of escitalopram. The onset of this episode could have been induced by a drug–drug interaction with an acute treatment by miconazole gingival adhesive tablets. The lack of pharmacokinetic data in the elderly population should prompt us to be especially cautious about prescription of this new formulation of miconazole in association with drugs metabolized by cytochromes P450 isoenzymes.
South Australia has a small population of older people compared to its geographic size. A Model of Service was developed to guide service delivery, with an Older Persons Mental Health Services project team appointed to guide the service. Their brief was to: develop and implement a Model of Service; develop and impart education on topics relating to mental health in late life to the clinicians, mental health teams, and aged care networks; coordinate the education sessions; develop a referral pathways document; develop an orientation package and orientation for clinicians; communicate with mental health teams and the aged care networks on the progress of the project; coordinate recruitment of clinicians; oversee data on the number of assessments undertaken; ensure that the key performance indicators were being met; and order resources for the clinicians (Nicholson and Nowak, 2010).
Papers submitted to International Psychogeriatrics undergo peer review, with each manuscript being assessed by two or more reviewers possessing expertise relevant to the paper's topic. The advice of reviewers is often highly valuable to authors working to strengthen papers through revision, and their recommendations are central to the process of determining what is published in International Psychogeriatrics.