A reevaluation of the duration of survival after the onset of dementia

Rapidly Progressive Alzheimer's Disease in Two Distinct Autopsy Cohorts

BACKGROUND

A rapidly progressive phenotype of Alzheimer's disease (AD) has been described in some prion disease cohorts. Limited information regarding rapidly progressive AD (rpAD) is available from longitudinal national cohorts.

OBJECTIVE

To compare the clinical characteristics of rpAD in two different national cohorts.

METHODS

A retrospective analysis was performed on AD subjects with available neuropathology in the National Alzheimer's Coordinating Center (NACC) database and among neuropathologically characterized AD cases from the National Prion Disease Pathology Surveillance Center (NPDPSC) that were evaluated for suspected prion disease. In the NACC cohort, rpAD was delineated by the lower 10th percentile of follow up duration from pre-dementia to death duration among subjects meeting pathological diagnosis of AD.

RESULTS

rpAD from the NPDPSC had a shorter mean symptom duration than the NACC identified rpAD cases (11.6 months versus 62.4 months) and were also younger at the time of their death (60.0 versus 81.8 years). NACC identified rpAD subjects, beginning from a predementia stage, had slower rate of MMSE change per year than NPDPSC cases (2.5 versus 6.0 points).

CONCLUSIONS

rpAD constitute an important subset of AD subjects in whom a rapid course of symptomatic clinical decline is noted, as confirmed in both national cohorts. rpAD was best characterized by survival time (≤3 years), as there were clear differences between the rpAD cohorts in terms of symptom duration, age at death, and MMSE change per year, likely due to the strong selection biases. rpAD could shed light on the biology of rate of progression in AD.

Semiparametric Model for Bivariate Survival Data Subject to Biased Sampling

To better understand the relationship between patient characteristics and their residual survival after an intermediate event such as the local cancer recurrence, it is of interest to identify patients with the intermediate event and then analyze their residual survival data. One challenge in analyzing such data is that the observed residual survival times tend to be longer than those in the target population, since patients who die before experiencing the intermediate event are excluded from the identified cohort. We propose to jointly model the ordered bivariate survival data using a copula model and appropriately adjusting for the sampling bias. We develop an estimating procedure to simultaneously estimate the parameters for the marginal survival functions and the association parameter in the copula model, and use a two-stage expectation-maximization algorithm. Using empirical process theory, we prove that the estimators have strong consistency and asymptotic normality. We conduct simulations studies to evaluate the finite sample performance of the proposed method. We apply the proposed method to two cohort studies to evaluate the association between patient characteristics and residual survival.

Dementia and Parkinson's Disease: Similar and Divergent Challenges in Providing Palliative Care

Dementia and Parkinson's disease are incurable neurological conditions. Patients often experience specific, complex, and varying needs along their disease trajectory. Current management typically employs a multidisciplinary team approach. Recognition is growing that this team approach should also address palliative care issues to optimize quality of life for patient and family caregivers, but it remains unclear how palliative care is best delivered. To inspire future service development and research, we compare the trajectories and conceptualization of palliative care between dementia and Parkinson's disease. Both Parkinson's disease and dementia are characterized by a protracted course, with progressive but fairly insidious development of disability. However, patients with Parkinson's disease may experience relatively stable periods initially but with time, a wide range of debilitating symptoms develops, many of which do not respond well to treatment. Eventually, dementia develops in most Parkinson patients, while motor disability develops in many dementia patients. In both diseases, symptoms such as pain, apathy, sleeping problems, falls, and a high caregiver burden are prevalent. Advance care planning has benefits in terms of being prepared before the disease progresses into a stage with communication problems or severe cognitive impairment. However, for both conditions, the protracted disease trajectories complicate conceptualization of palliative care through different stages of the disease, with pertinent questions such as when to offer what interventions pro-actively. Given the similarities and differences, we should develop palliative approaches that are partially generic and partially disease-specific. These should be integrated seamlessly with disease-specific care. Substantial research is already being performed on dementia palliative care. This may also inform the further development of palliative care for Parkinson's disease, including an evaluation of palliative interventions and services.

Adiposity in middle and old age and risk of death from dementia: 40-year follow-up of 19,000 men in the Whitehall study

AIMS AND OBJECTIVES

to examine the hypothesis that obesity is protective for dementia, we compared the associations of death from dementia with body weight and body mass index (BMI) in both middle and old age.

DESIGN

height and weight were measured in a prospective study of 19,019 middle-aged men in the Whitehall study in 1967-70 and in 6,158 surviving participants at resurvey in 1997. Cox regression was used to examine the associations of death from dementia over a 40-year period with weight or BMI measured by health professionals in middle and old age adjusting for age, smoking habits, employment grade and marital status.

SETTING

central government employees in London, UK.

MAIN OUTCOMES MEASURE

death due to dementia in 320 participants.

RESULTS

body weight measured in middle age was weakly inversely associated with death from dementia (hazard ratio 0.98 [95%CI: 0.97-0.99] per kg), but neither height nor BMI were related to risk of dementia. In contrast, body weight in old age was more strongly inversely related to deaths from dementia (0.96; [0.95-0.98] per kg) as was BMI (0.92 [0.86-0.97] per kg/m2). Weight loss over the 30 years between baseline and resurvey was associated with a higher risk of death from dementia, with an adjusted HR per kg/30 years of 1.04 [95%CI: 1.02-1.08] and the association with loss of BMI was even stronger (adjusted HR of 1.10 [1.03-1.19]) per kg/m2 decrease.

CONCLUSIONS

the stronger inverse associations of deaths from dementia with BMI in old age, compared with middle age, together with strong positive associations of loss of BMI or body weight between middle and old age casts doubt on previous suggestions that obesity protects against death from dementia.

Is Dementia More Fatal Than Previously Estimated? A Population-based Prospective Cohort Study

Dementia increases the risk of mortality (ROM) in the elderly and estimates of hazard ratio (HR) of dementia for mortality have ranged from 1.7 to 6.3. However, previous studies may have underestimated ROM of dementia due to length bias, which occurs when failing to include the persons with rapidly progressive diseases, who died before they could be included in the study. This population-based prospective cohort study conducted on 6,752 randomly sampled Koreans, aged 60 years or older (the Korean Longitudinal Study on Cognitive Aging and Dementia). Cognitive disorders were evaluated at baseline and 2-year follow-up using the Korean version of the Consortium to Establish a Registry for Alzheimer's Disease Assessment Packet (CERAD-K), and prevalent and incident cases of dementia were identified. The participants' deaths were confirmed through the National Mortality Database of Statistics Korea. We compared the ROM between prevalent and incident dementia, and estimated HR of dementia for mortality using Cox proportional hazards model. Of the 5,097 responders to the 2-year follow-up assessment, 150 participants had dementia from the baseline (prevalent dementia), and 95 participants developed dementia during the 2-year follow-up period (incident dementia). The ROM of participants with incident dementia was about 3 times higher than the ROM of those with prevalent dementia (HR = 3.04, 95% confidence interval [CI] = 1.34-6.91). Compared to cognitively normal participants at both the baseline and 2-year follow-up assessments, the ROM of those with incident dementia approximately 8 times higher (HR = 8.37, 95 % CI = 4.23-16.54). In conclusion, the ROM of dementia using prevalent cases was underestimated due to length bias, and dementia may be much more fatal than previously estimated. In clinical settings, the ROM of dementia warrants the attention of physicians, particularly in recently incident dementia cases.

Life Expectancy With and Without Dementia: A Population-Based Study of Dementia Burden and Preventive Potential

Reliable population estimates of life expectancy with dementia are required for shaping health-care policy. From the Dutch, population-based Rotterdam Study, 10,348 persons were followed during 1990-2015 for dementia and death. We created multistate lifetables, and assessed the effect of postponing disease onset. During 120,673 person-years, 1,666 persons developed dementia, and 6,150 died. Overall life expectancy of women ranged from 18.0 years (95% confidence interval (CI): 17.8, 18.2) at age 65 to 2.3 years (95% CI: 2.2, 2.3) at age 95. Of total life expectancy at age 65, 5.7% (1.0 year (95% CI: 1.0, 1.1)) was lived with dementia, increasing with age to 42.1% (1.0 year, 95% CI: 0.9, 1.0) at age 95. For men, life expectancy ranged from 15.6 years (95% CI: 15.4, 15.9) at age 65 to 1.8 years (95% CI: 1.7, 1.8) at age 95, of which 3.7% (95% CI: 0.6 year, 0.5, 0.6) and 35.3% (95% CI: 0.6 year, 0.5, 0.7), respectively, was lived with dementia. Postponing dementia onset by 1-3 years resulted in 25%-57% reductions in years lived with dementia. Survival after diagnosis ranged from 6.7 years (95% CI: 5.3, 8.1) before age 70, to 2.6 years (95% CI: 2.3, 2.9) after age 90. The burden of dementia on individuals and society in terms of healthy life-years lost is large but could potentially be mitigated by preventive interventions at the population level.

Model diagnostics for the proportional hazards model with length-biased data

Length-biased data are frequently encountered in prevalent cohort studies. Many statistical methods have been developed to estimate the covariate effects on the survival outcomes arising from such data while properly adjusting for length-biased sampling. Among them, regression methods based on the proportional hazards model have been widely adopted. However, little work has focused on checking the proportional hazards model assumptions with length-biased data, which is essential to ensure the validity of inference. In this article, we propose a statistical tool for testing the assumed functional form of covariates and the proportional hazards assumption graphically and analytically under the setting of length-biased sampling, through a general class of multiparameter stochastic processes. The finite sample performance is examined through simulation studies, and the proposed methods are illustrated with the data from a cohort study of dementia in Canada.

Screening mammography among nursing home residents in the United States: Current guidelines and practice

OBJECTIVE

United States (US) guidelines regarding when to stop routine breast cancer screening remain unclear. No national studies to-date have evaluated the use of screening mammography among US long-stay nursing home residents. This cross-sectional study was designed to identify prevalence, predictors, and geographic variation of screening mammography among that population in the context of current US guidelines.

MATERIALS AND METHODS

Screening mammography prevalence, identified with Physician/Supplier Part B claims and stratified by guideline age classification (65-74, ≥75 years), was estimated for all women aged ≥65 years residing in US Medicare- and Medicaid- certified nursing homes (≥1 year) with an annual Minimum Data Set (MDS) 3.0 assessment, continuous Medicare Part B enrollment, and no clinical indication for screening mammography as of 2011 (n = 389,821). The associations between resident- and regional- level factors, and screening mammography, were estimated by crude and adjusted prevalence ratios from robust Poisson regressions clustered by facility.

RESULTS

Women on average were 85.4 (standard deviation ±8.1) years old, 77.9% were disabled, and 76.3% cognitively impaired. Screening mammography prevalence was 7.1% among those aged 65-74 years (95% Confidence Interval (CI): 6.8%-7.3%) and 1.7% among those ≥75 years (95% CI, 1.7%-1.8%), with geographic variation observed. Predictors of screening in both age groups included race, cognitive impairment, frailty, hospice, and some comorbidities.

CONCLUSIONS

These results shed light on the current screening mammography practices in US nursing homes. Thoughtful consideration about individual screening recommendations and the implementation of more clear guidelines for this special population are warranted to prevent overscreening.

Survival and years of life lost in various aetiologies of dementia, mild cognitive impairment (MCI) and subjective cognitive decline (SCD) in Norway

INTRODUCTION

Alzheimer's disease patients are reported to have higher survival rate compared to patients with vascular dementia or dementia with Lewy bodies. There is a paucity of studies investigating survival including persons with cognitive decline and dementia of various aetiologies.

OBJECTIVES

We aimed to compare survival for patients with subjective cognitive decline, mild cognitive impairment, Alzheimer's disease, vascular dementia, mixed Alzheimer's/vascular dementia, dementia with Lewy bodies/Parkinson's disease, and other dementias compared to the general Norwegian population, taking into account the role of gender, cognitive function, function in everyday activities, comorbidity and education.

METHODS

Patients (N = 4682), ≥65 years, in the The Norwegian register of persons assessed for cognitive symptoms (NorCog) during 2009-2017 were followed for mortality in the National Registry until January 2018. Flexible parametric survival models were applied to estimate relative survival, life expectancy and years of life lost for diagnostic groups compared with the general population.

RESULTS

Patients with vascular dementia or dementia with Lewy bodies/Parkinson's had the shortest survival, followed by mixed dementia, Alzheimer's disease, unspecified dementia, mild cognitive impairment and subjective cognitive decline. At age 70 years, men with vascular dementia or dementia with Lewy bodies/Parkinson's had life expectancy of 4.7 years, which corresponded to 10.3 years of life lost compared to the general population. Years of life lost for other diagnoses were 10.0 years for mixed dementia, 9.2 years for Alzheimer's disease, 9.3 years for other dementias, 5.2 years for mild cognitive impairment and 2.2 years for subjective cognitive decline. Corresponding years of life lost in women were: 12.7 years, 10.5 years, 9.8 years, 10.6 years, 7.8 years, and 2.6 years. Poor relative survival among dementia patients was associated with male gender, comorbidity, low cognitive function, and low function in activities of daily living.

CONCLUSIONS

Compared with the general population, patients with subjective cognitive decline had no significant loss in life expectancy, while patients with mild cognitive impairment and all dementia subtypes had large losses, especially those with a diagnosis of vascular dementia or dementia with Lewy bodies/Parkinson's.

16-Year Survival of the Canadian Collaborative Cohort of Related Dementias

Background Survival estimates are integral to care for patients diagnosed with dementia. Few Canadian studies have carried out long-term follow-up of well-described cohorts, analyzing survival related to multiple risk factors. Methods Survival analysis of an inception cohort enrolled at a British Columbia (BC) tertiary dementia referral clinic between 1997 and 1999 was undertaken. Vital status was completed for 168 patients diagnosed with dementia. An evaluation of the effects of demographics, vascular risk factors, cognitive and functional ratings, apolipoprotein 4-status, and cholinesterase use on survival was performed using a log-rank test and time-dependent Cox regression. Survival of this dementia cohort was compared with the age-matched life expectancy of persons in BC. Results In all, 158/168 (94.0%) subjects died over 16.6 years, with a median survival of 7.08 years. Risk factors associated with shorter survival in dementia groups included age of onset ≥80 (hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.05-2.32); greater functional disability (Disability Assessment for Dementia<55% [HR 1.47, 95% CI 1.04-2.08]); and cumulative medical illness severity (Cumulative Illness Rating Scale≥7 [HR 1.51, 95% CI 1.08-2.12)]. Compared with the BC population, years of potential life lost for dementia subjects aged <65 was 15.36 years, and for dementia subjects aged ≥80 it was 1.82 years. Conclusions Survival in dementia subjects is shorter than population life expectancies for each age strata, with greatest impact on younger patients. For people diagnosed with dementia, age ≥80 years, cumulative medical illness severity, and functional disabilities are the most significant survival predictors and can be used to guide prognosis.

Missing Information Principle: A Unified Approach for General Truncated and Censored Survival Data Problems

It is well known that truncated survival data are subject to sampling bias, where the sampling weight depends on the underlying truncation time distribution. Recently, there has been a rising interest in developing methods to better exploit the information about the truncation time, thus the sampling weight function, to obtain more efficient estimation. In this paper, we propose to treat truncation and censoring as "missing data mechanism" and apply the missing information principle to develop a unified framework for analyzing left-truncated and right-censored data with unspecified or known truncation time distributions. Our framework is structured in a way that is easy to understand and enjoys a great flexibility for handling different types of models. Moreover, a new test for checking the independence between the underlying truncation time and survival time is derived along the same line. The proposed hypothesis testing procedure utilizes all observed data and hence can yield a much higher power than the conditional Kendall's tau test that only involves comparable pairs of observations under truncation. Simulation studies with practical sample sizes are conducted to compare the performance of the proposed method with its competitors. The proposed methodologies are applied to a dementia study and a nursing house study for illustration.

Simple and fast overidentified rank estimation for right-censored length-biased data and backward recurrence time

Length-biased survival data subject to right-censoring are often collected from a prevalent cohort. However, informative right censoring induced by the sampling design creates challenges in methodological development. While certain conditioning arguments could circumvent the problem of informative censoring, related rank estimation methods are typically inefficient because the marginal likelihood of the backward recurrence time is not ancillary. Under a semiparametric accelerated failure time model, an overidentified set of log-rank estimating equations is constructed based on the left-truncated right-censored data and backward recurrence time. Efficient combination of the estimating equations is simplified by exploiting an asymptotic independence property between two sets of estimating equations. A fast algorithm is studied for solving non-smooth, non-monotone estimating equations. Simulation studies confirm that the overidentified rank estimator can have a substantially improved estimation efficiency compared to just-identified rank estimators. The proposed method is applied to a dementia study for illustration.

Mortality Risk after Diagnosis of Early-Onset Alzheimer's Disease versus Late-Onset Alzheimer's Disease: A Propensity Score Matching Analysis

BACKGROUND/OBJECTIVE

We aimed to compare the risk of mortality in patients with early-onset Alzheimer's disease (EOAD) versus those with late-onset AD (LOAD) using a large number of study subjects. We applied propensity score matching (PSM) to minimize confounding biases in the comparison between EOAD and LOAD.

METHODS

We obtained data from elderly Korean subjects with AD (n = 3,611) at baseline from the CREDOS cohort study, which was conducted from November 2005 to July 2013. We conducted PSM to reduce the bias due to confounding variables related to survival in patients with AD. The risks of mortality associated with EOAD and LOAD were evaluated by Cox proportional hazard analyses, controlling for relevant covariates.

RESULTS

After propensity score matching, 312 subjects with EOAD and 624 subjects with LOAD were selected for further analysis. The Cox proportional hazard analysis showed that patients with EOAD are at a greater risk for mortality compared to those with LOAD (Hazard Ratio: 2.01, 95% CI: 1.01-4.00, p-value: 0.04) when controlling for the direct effect of aging on mortality. The results did not change after adjusting for age at diagnosis, general cognitive function, nutritional factor related to body mass index, and physical disability using activities of daily living. The results support the assumption that EOAD takes a more malignant course than LOAD.

CONCLUSIONS

Our results provide support for the idea that EOAD takes a clinical course that is distinct from that of LOAD, especially as pertains to the risk of mortality.

Review: Impact of Helicobacter pylori on Alzheimer's disease: What do we know so far?

BACKGROUND

Helicobacter pylori has changed radically gastroenterologic world, offering a new concept in patients' management. Over time, more medical data gave rise to diverse distant, extragastric manifestations and interactions of the "new" discovered bacterium. Special interest appeared within the field of neurodegenerative diseases and particularly Alzheimer's disease, as the latter and Helicobacter pylori infection are associated with a large public health burden and Alzheimer's disease ranks as the leading cause of disability. However, the relationship between Helicobacter pylori infection and Alzheimer's disease remains uncertain.

METHODS

We performed a narrative review regarding a possible connection between Helicobacter pylori and Alzheimer's disease. All accessible relevant (pre)clinical studies written in English were included. Both affected pathologies were briefly analyzed, and relevant studies are discussed, trying to focus on the possible pathogenetic role of this bacterium in Alzheimer's disease.

RESULTS

Data stemming from both epidemiologic studies and animal experiments seem to be rather encouraging, tending to confirm the hypothesis that Helicobacter pylori infection might influence the course of Alzheimer's disease pleiotropically. Possible main mechanisms may include the bacterium's access to the brain via the oral-nasal-olfactory pathway or by circulating monocytes (infected with Helicobacter pylori due to defective autophagy) through disrupted blood-brain barrier, thereby possibly triggering neurodegeneration.

CONCLUSIONS

Current data suggest that Helicobacter pylori infection might influence the pathophysiology of Alzheimer's disease. However, further large-scale randomized controlled trials are mandatory to clarify a possible favorable effect of Helicobacter pylori eradication on Alzheimer's disease pathophysiology, before the recommendation of short-term and cost-effective therapeutic regimens against Helicobacter pylori-related Alzheimer's disease.

Report by the Spanish Foundation of the Brain on the social impact of Alzheimer disease and other types of dementia

INTRODUCTION

Knowledge of the socioeconomic impact of dementia-related disorders is essential for appropriate management of healthcare resources and for raising social awareness.

METHODS

We performed a literature review of the published evidence on the epidemiology, morbidity, mortality, associated disability and dependence, and economic impact of dementia and Alzheimer disease (AD) in Spain.

CONCLUSIONS

Most population studies of patients older than 65 report prevalence rates ranging from 4% to 9%. Prevalence of dementia and AD is higher in women for nearly every age group. AD is the most common cause of dementia (50%-70% of all cases). Dementia is associated with increased morbidity, mortality, disability, and dependence, and results in a considerable decrease in quality of life and survival. Around 80% of all patients with dementia are cared for by their families, which cover a mean of 87% of the total economic cost, resulting in considerable economic and health burden on caregivers and loss of quality of life. The economic impact of dementia is huge and difficult to evaluate due to the combination of direct and indirect costs. More comprehensive programmes should be developed and resources dedicated to research, prevention, early diagnosis, multidimensional treatment, and multidisciplinary management of these patients in order to reduce the health, social, and economic burden of dementia.

Cardiovascular Screening and Primary Prevention in Older Adults

Evidence for preventive screening and therapeutic intervention for primary prevention of cardiovascular disease is limited for older adults. In this article, we review screening and prevention strategies, including lifestyle, modifiable risk factors, and medications, that may be considered in older adults, with a focus on those ≥75 years, accounting for age, frailty and functional status, medical conditions, and life expectancy.

Analysis of restricted mean survival time for length-biased data

In clinical studies with time-to-event outcomes, the restricted mean survival time (RMST) has attracted substantial attention as a summary measurement for its straightforward clinical interpretation. When the data are subject to length-biased sampling, which is frequently encountered in observational cohort studies, existing methods to estimate the RMST are not applicable. In this article, we consider nonparametric and semiparametric regression methods to estimate the RMST under the setting of length-biased sampling. To assess the covariate effects on the RMST, a semiparametric regression model that directly relates the covariates and the RMST is assumed. Based on the model, we develop unbiased estimating equations to obtain consistent estimators of covariate effects by properly adjusting for informative censoring and length bias. Stochastic process theories are used to establish the asymptotic properties of the proposed estimators. We investigate the finite sample performance through simulations and illustrate the methods by analyzing a prevalent cohort study of dementia in Canada.

Exploring the enablers and barriers to implementing the Medication Appropriateness Tool for Comorbid Health conditions during Dementia (MATCH-D) criteria in Australia: a qualitative study

OBJECTIVES

The Medication Appropriateness Tool for Comorbid Health conditions in Dementia (MATCH-D) criteria provide expert consensus guidance about medication use for people with dementia. This study aimed to identify enablers and barriers to implementing the criteria in practice.

SETTING

Participants came from both rural and metropolitan communities in two Australian states.

PARTICIPANTS

Focus groups were held with consumers, general practitioners, nurses and pharmacists.

OUTCOMES

data were analysed thematically.

RESULTS

Nine focus groups were conducted. Fifty-five participants validated the content of MATCH-D, appraising them as providing patient-centred principles of care. Participants identified potential applications (including the use of MATCH-D as a discussion aid or educational tool for consumers about medicines) and suggested supporting resources.

CONCLUSION

Participants provided insights into applying MATCH-D in practice and suggested resources to be included in an accompanying toolkit. These data provide external validation of MATCH-D and an empiric basis for their translation to practice. Following resource development, we plan to evaluate the feasibility and efficacy of implementation in practice.

Medication appropriateness tool for co-morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel

Background

Medication management for people living with dementia is a complex task as it is unclear what constitutes optimal medication management in this population due to the shifting focus of health priorities and the balance between the benefits and harms of medications.

Aim

This study sought expert opinion to create a consensus list to define appropriate medication management of co‐morbidities for people with dementia.

Methods

This study used the Delphi technique. We invited multidisciplinary experts in geriatric therapeutics including pharmacists, doctors, nurse practitioners, a patient advocate and a psychologist to participate. Participants were asked to engage into three or more rounds of questioning. Round 1 was a questionnaire comprised of one question defining dementia and seven open‐ended questions about appropriate management of co‐morbidities in people with dementia. Two investigators qualitatively analysed the responses to questions from Round 1 using thematic analysis. The results of this analysis were provided to participants as statements in the Round 2 survey. The participants were asked to rate their agreement with each statement on a 5‐point Likert scale. The median and interquartile range (IQR) were calculated for the responses to each statement. Consensus was pre‐specified as an IQR less than or equal to 1. Statements where consensus was not achieved were presented to participants in Round 3. The Round 2 median and IQR values were provided and participants were again asked to rate their agreement with each statement on a 5‐point Likert scale. The statements where participants agreed or strongly agreed were included in the Medication Appropriateness Tool for Co‐morbid Health conditions in Dementia criteria.

Results

Fifty‐seven experts agreed to participate in the study, of whom 58% were pharmacists and 36% were medical practitioners. Fifty‐five participants completed the Round 1 (95% response rate). A total of 128 statements was included in the Round 2 survey. Consensus was reached on 93 statements in Round 2 (n = 48 responders, 84% response rate) and on 18 statements in Round 3 (n = 43 responders, 75% response rate). The participants reached consensus on 111 of 128 statements. Of these statements, 67 statements were included in the Medication Appropriateness Tool for Co‐morbid Health conditions in Dementia criteria. The statements were in the broad themes of preventative medication, symptom management, disease progression, psychoactive medication, treatment goals, principles of medication use, side‐effects and medication reviews.

Discussion

This research provides consensus‐based guidance for clinicians who manage co‐morbid health conditions in people with dementia.

Dementia prevalence and incidence in a federation of European Electronic Health Record databases: The European Medical Informatics Framework resource

INTRODUCTION

The European Medical Information Framework consortium has assembled electronic health record (EHR) databases for dementia research. We calculated dementia prevalence and incidence in 25 million persons from 2004 to 2012.

METHODS

Six EHR databases (three primary care and three secondary care) from five countries were interrogated. Dementia was ascertained by consensus harmonization of clinical/diagnostic codes. Annual period prevalences and incidences by age and gender were calculated and meta-analyzed.

RESULTS

The six databases contained 138,625 dementia cases. Age-specific prevalences were around 30% of published estimates from community samples and incidences were around 50%. Pooled prevalences had increased from 2004 to 2012 in all age groups but pooled incidences only after age 75 years. Associations with age and gender were stable over time.

DISCUSSION

The European Medical Information Framework initiative supports EHR data on unprecedented number of people with dementia. Age-specific prevalences and incidences mirror estimates from community samples in pattern at levels that are lower but increasing over time.

Poor caregiver mental health predicts mortality of patients with neurodegenerative disease

Dementia and other neurodegenerative diseases cause profound declines in functioning; thus, many patients require caregivers for assistance with daily living. Patients differ greatly in how long they live after disease onset, with the nature and severity of the disease playing an important role. Caregiving can also be extremely stressful, and many caregivers experience declines in mental health. In this study, we investigated the role that caregiver mental health plays in patient mortality. In 176 patient-caregiver dyads, we found that worse caregiver mental health predicted greater patient mortality even when accounting for key risk factors in patients (i.e., diagnosis, age, sex, dementia severity, and patient mental health). These findings highlight the importance of caring for caregivers as well as patients when attempting to improve patients' lives.

Nested case-control study designs for left-truncated survival data

The determination of risk factors for disease incidence has been the subject of much epidemiologic research. With this goal a common study design entails the follow-up of an initially disease-free cohort, keeping track of the dates of disease incidence (onset) and ascertaining covariate (putative risk factor) information on the full cohort. However, the collection of certain covariate information on all study subjects may be prohibitively expensive and, therefore, the nested case-control study has commonly been used. The high cost of full covariate information on all subjects also arises when determining risk factors for "failure," death say, "following" disease onset, in particular, in a prevalent cohort study with follow-up; in such a study a cohort of subjects with existing disease is followed. We here adapt nested case-control designs to the setting of a prevalent cohort study with follow-up, a topic previously not addressed in the literature. We provide the partial likelihood under risk set sampling and state the asymptotic properties of the estimated covariate effects and baseline cumulative hazard. We address the following design questions in the context of prevalent cohort studies with follow-up: How many subjects should be included in the sampled risk sets for efficient estimation? In what way is the proportion of censored subjects associated with the benefit of a nested case-control design? What proportion of overall variance is attributable to risk set sampling? This work is motivated by the anticipated analysis of data on survival with Parkinson's Disease, being collected as part of the ongoing Canadian Longitudinal Study on Aging.

Survival after dementia diagnosis in five racial/ethnic groups

INTRODUCTION

Information on anticipated survival time after dementia diagnosis among racially/ethnically diverse patients is needed to plan for care and evaluate disparities.

METHODS

Dementia-free health care members aged ≥64 years were followed (1/1/2000-12/31/2013) for dementia diagnosis and subsequent survival (n = 23,032 Asian American; n = 18,778 African American; n = 21,000 Latino; n = 4543 American Indian/Alaska Native; n = 206,490 white). Kaplan-Meier curves were estimated for survival after dementia diagnosis by race/ethnicity. We contrasted mortality patterns among people with versus without dementia using Cox proportional hazards models.

RESULTS

After dementia diagnosis (n = 59,494), whites had shortest median survival (3.1 years), followed by American Indian/Alaska Natives (3.4 years), African Americans (3.7 years), Latinos (4.1 years), and Asian Americans (4.4 years). Longer postdiagnosis survival among racial/ethnic minorities compared with whites persisted after adjustment for comorbidities. Racial/ethnic mortality inequalities among dementia patients mostly paralleled mortality inequalities among people without dementia.

DISCUSSION

Survival after dementia diagnosis differs by race/ethnicity, with shortest survival among whites and longest among Asian Americans.

Long-term effect of galantamine on cognitive function in patients with Alzheimer's disease versus a simulated disease trajectory: an observational study in the clinical setting

BACKGROUND

Long-term maintenance of cognitive function is an important goal of treatment for Alzheimer's disease (AD), but evidence about the long-term efficacy of cholinesterase inhibitors is sparse. To evaluate the long-term efficacy and safety of galantamine for AD in routine clinical practice, we conducted a 72-week post-marketing surveillance study. The effect of galantamine on cognitive function was estimated in comparison with a simulated disease trajectory.

PATIENTS AND METHODS

Patients with mild-to-moderate AD received flexible dosing of galantamine (16-24 mg/day) during this study. Cognitive function was assessed by the mini mental state examination (MMSE) and the clinical status was determined by the Clinical Global Impression-Improvement (CGI-I). Changes of the MMSE score without treatment were estimated in each patient using Mendiondo's model. Generalized linear mixed model analysis was performed to compare the simulated MMSE scores with the actual scores.

RESULTS

Of the 661 patients who were enrolled, 642 were evaluable for safety and 554 were assessed for efficacy. The discontinuation rate was 46.73%. Cognitive decline indicated by the mean change of actual MMSE scores was significantly smaller than the simulated decline. Individual analysis demonstrated that >70% of patients had better actual MMSE scores than their simulated scores. Significant improvement of CGI-I was also observed during the observation period. Adverse events occurred in 28.5% of patients and were serious in 8.41%. The reported events generally corresponded with the safety profile of galantamine in previous studies.

CONCLUSION

These findings support the long-term efficacy of galantamine for maintaining cognitive function and the clinical state in AD patients. Treatment with galantamine was generally safe. Importantly, this study revealed that galantamine improved cognitive function above the predicted level in >70% of the patients.

Nonparametric and semiparametric regression estimation for length-biased survival data

For the past several decades, nonparametric and semiparametric modeling for conventional right-censored survival data has been investigated intensively under a noninformative censoring mechanism. However, these methods may not be applicable for analyzing right-censored survival data that arise from prevalent cohorts when the failure times are subject to length-biased sampling. This review article is intended to provide a summary of some newly developed methods as well as established methods for analyzing length-biased data.

Cumulative dosages of antipsychotic drugs are associated with increased mortality rate in patients with Alzheimer's dementia

OBJECTIVE

We wished to investigate the effects of cumulative dosages of antipsychotic drug in Alzheimer's dementia, when controlling for known risk factors, including current antipsychotic exposure, on all-cause mortality.

METHOD

We utilized a nationwide, population-based, retrospective cohort study design with mortality as outcome in individual patients diagnosed with Alzheimer's dementia.

RESULTS

We included a total of 45 894 patients and followed them for 3 803 996 person-years in total, presenting 27 894 deaths in the study population. Cumulative antipsychotic exposure increased mortality: more than 0 Daily Defined Dosage (DDDs) but less than 90: HR 2.20, 95% CI (2.14-2.27), P < 0.001; more than or equal to 90 DDDs but less than 365: HR 1.81, 95% CI (1.74-1.89), P < 0.001; more than or equal to 365 DDDs but less than 730: HR 1.38, 95% CI (1.428-1.49), P < 0.001; and more than or equal to 730 DDDs: HR 1.06, 95% CI (0.95-1.18), P = 0.322, when controlling for proxy markers of severity, somatic and mental comorbid disorders.

CONCLUSION

In this nationwide cohort study of 45 894 patients diagnosed with Alzheimer's dementia, we found that cumulative dosages of antipsychotic drugs were associated with increased mortality rates.

Health Insurance Dynamics: Methodological Considerations and a Comparison of Estimates from Two Surveys

OBJECTIVE

To highlight key methodological issues in studying insurance dynamics and to compare estimates across two commonly used surveys.

DATA SOURCES/STUDY SETTING

Nonelderly uninsured adults and children sampled between 2001 and 2011 in the Medical Expenditure Panel Survey and the Survey of Income and Program Participation.

STUDY DESIGN

We utilized nonparametric Kaplan-Meier methods to estimate quantiles (25th, 50th, and 75th percentiles) in the distribution of uninsured spells. We compared estimates obtained across surveys and across different methodological approaches to address issues like attrition, seam bias, censoring and truncation, and survey weighting method.

DATA COLLECTION/EXTRACTION METHODS

All data were drawn from publicly available household surveys.

PRINCIPAL FINDINGS

Estimated uninsured spell durations in the MEPS were longer than those observed in the SIPP. There were few changes in spell durations between 2001 and 2011, with median durations of 14 months among adults and 5-7 months among children in the MEPS, and 8 months (adults) and 4 months (children) in the SIPP.

CONCLUSIONS

The use of panel survey data to study insurance dynamics presents a unique set of methodological challenges. Researchers should consider key analytic and survey design trade-offs when choosing which survey can best suit their research goals.

Cognitively-Related Basic Activities of Daily Living Impairment Greatly Increases the Risk of Death in Alzheimers Disease

INTRODUCTION

Some Alzheimer's disease (AD) patients die without ever developing cognitively impaired basic activities of daily living (basic ADL), which may reflect slower disease progression or better compensatory mechanisms. Although impaired basic ADL is related to disease severity, it may exert an independent risk for death. This study examined the association between impaired basic ADL and survival of AD patients, and proposed a multistate approach for modeling the time to death for patients who demonstrate different patterns of progression of AD that do or do not include basic ADL impairment.

METHODS

1029 patients with probable AD at the Baylor College of Medicine Alzheimer's Disease and Memory Disorders Center met the criteria for this study. Two complementary definitions were used to define development of basic ADL impairment using the Physical Self-Maintenance Scale score. A weighted Cox regression model, including a time-dependent covariate (development of basic ADL impairment), and a multistate survival model were applied to examine the effect of basic ADL impairment on survival.

RESULTS

As expected decreased ability to perform basic ADL at baseline, age at initial visit, years of education, and sex were all associated with significantly higher mortality risk. In those unimpaired at baseline, the development of basic ADL impairment was also associated with a much greater risk of death (hazard ratios 1.77-4.06) over and above the risk conferred by loss of MMSE points. A multi-state Cox model, controlling for those other variables quantified the substantive increase in hazard ratios for death conferred by the development of basic ADL impairment by two definitions and can be applied to calculate the short term risk of mortality in individual patients.

CONCLUSIONS

The current study demonstrates that the presence of basic ADL impairment or the development of such impairments are important predictors of death in AD patients, regardless of severity.

Oxidative Stress in Neurodegenerative Diseases

The pathophysiologies of neurodegenerative diseases, including amyotrophic lateral sclerosis (ALS), Parkinson's disease (PD), and Alzheimer's disease (AD), are far from being fully explained. Oxidative stress (OS) has been proposed as one factor that plays a potential role in the pathogenesis of neurodegenerative disorders. Clinical and preclinical studies indicate that neurodegenerative diseases are characterized by higher levels of OS biomarkers and by lower levels of antioxidant defense biomarkers in the brain and peripheral tissues. In this article, we review the current knowledge regarding the involvement of OS in neurodegenerative diseases, based on clinical trials and animal studies. In addition, we analyze the effects of the drug-induced modulation of oxidative balance, and we explore pharmacotherapeutic strategies for OS reduction.

Geriatric assessment factors are associated with mortality after hospitalization in older adults with cancer

PURPOSE

Survival in older adults with cancer varies given differences in functional status, comorbidities, and nutrition. Prediction of factors associated with mortality, especially in hospitalized patients, allows physicians to better inform their patients about prognosis during treatment decisions. Our objective was to analyze factors associated with survival in older adults with cancer following hospitalization.

METHODS

Through a retrospective cohort study, we reviewed 803 patients who were admitted to Barnes-Jewish Hospital's Oncology Acute Care of Elders (OACE) unit from 2000 to 2008. Data collected included geriatric assessments from OACE screening questionnaires as well as demographic and medical history data from chart review. The primary end point was time from index admission to death. The Cox proportional hazard modeling was performed.

RESULTS

The median age was 72.5 years old. Geriatric syndromes and functional impairment were common. Half of the patients (50.4 %) were dependent in one or more activities of daily living (ADLs), and 74 % were dependent in at least one instrumental activity of daily living (IADLs). On multivariate analysis, the following factors were significantly associated with worse overall survival: male gender; a total score <20 on Lawton's IADL assessment; reason for admission being cardiac, pulmonary, neurologic, inadequate pain control, or failure to thrive; cancer type being thoracic, hepatobiliary, or genitourinary; readmission within 30 days; receiving cancer treatment with palliative rather than curative intent; cognitive impairment; and discharge with hospice services.

CONCLUSIONS

In older adults with cancer, certain geriatric parameters are associated with shorter survival after hospitalization. Assessment of functional status, necessity for readmission, and cognitive impairment may provide prognostic information so that oncologists and their patients make more informed, individualized decisions.

The association between caregiver well-being and care provided to persons with Alzheimer's disease and related disorders

BACKGROUND

Alzheimer's disease and related disorders (ADRD) are some of the leading causes of morbidity in developed nations. Unpaid family caregivers are primarily responsible for providing the care and support needed by persons with ADRD. In the process of caring for their loved ones with ADRD, caregivers often have to deal with multiple challenges, including their own deteriorating well-being and overall quality-of-life (QoL). A recent systematic review showed that very little research has been undertaken to study the relationship between AD caregiver QoL and the level or quality of care that caregivers provide to their loved ones. In this study, we investigate the relationships between caregiver well-being and the care provided to persons with ADRD.

METHODS

We used 12-month follow-up data from the Philadelphia site (n = 125) of the National Institutes of Health (NIH) multi-site study, Resources for Enhancing Alzheimer's Caregiver Health (REACH I) to examine the relationship between caregiver well-being and the level or quality of care provided while adjusting for important covariates (e.g., age, income, and years since caregiving). Caregivers who participated in REACH I had to be at least 21 years of age and they had to be providing at least 4 h of care per day for 6 months or more to a live-in loved one with ADRD. Linear regression analysis was used to examine the relationships between well-being and the level or quality of care provided to persons with ADRD.

RESULTS

Of the 255 caregivers who participated in the REACH I study, 125 (49.0 %) remained after 12 months of follow-up. Comparisons of participants at the 12-month follow-up and participants who were lost to follow-up showed that these two sets of participants were not statistically significantly different on any of the variables examined in this study. Linear regression analysis showed that there was no statistically significant association between caregiver well-being and level or quality of care provided.

CONCLUSIONS

Further research is required to investigate the factors associated with level and quality of care provided to persons with ADRD, and whether caregiver well-being (or QoL in general) is a contributor.

Sample size calculations for prevalent cohort designs

Cross-sectional prevalent cohort design has drawn considerable interests in the studies of association between risk factors and time-to-event outcome. The sampling scheme in such design gives rise to length-biased data that require specialized analysis strategy but can improve study efficiency. The power and sample size calculation methods are however lacking for studies with prevalent cohort design, and using the formula developed for traditional survival data may overestimate sample size. We derive the sample size formulas that are appropriate for the design of cross-sectional prevalent cohort studies, under the assumptions of exponentially distributed event time and uniform follow-up for cross-sectional prevalent cohort design. We perform numerical and simulation studies to compare the sample size requirements for achieving the same power between prevalent cohort and incident cohort designs. We also use a large prospective prevalent cohort study to demonstrate the procedure. Using rigorous designs and proper analysis tools, the prospective prevalent cohort design can be more efficient than the incident cohort design with the same total sample sizes and study durations.

Alcohol, wine and mental health: focus on dementia and stroke

The relative risks of coronary heart disease (CHD) and overall mortality are reduced by moderate consumption of alcoholic beverages, particularly wine, which has major implications for public health. It appears likely that this beneficial effect of alcohol will soon be extended to some mental disorders. Although data on psychosis and mood and anxiety disorders are currently lacking, it appears that the relative risks of developing ischaemic stroke and Alzheimer's or vascular dementia are also lowered by moderate alcohol consumption. Such findings are still tentative because of the inherent methodological problems involved in Population-based epidemiological studies, and it is unclear whether the benefit can be ascribed to alcohol itself or to other constituents specific to wine such as polyphenols. Plausible biological mechanisms have been advanced for the protective effect of alcohol and wine against CHD, many of which will also play roles in their protective actions against cerebrovascular disease and dementia. The specific antioxidant properties of wine polyphenols may be particularly important in preventing Alzheimer's disease. Because of the substantially unpredictable risk of progression to problem drinking and alcohol abuse, the most sensible advice to the general public is that heavy drinkers should drink less or not at all, that abstainers should not be indiscriminately encouraged to begin drinking for health reasons, and that light to moderate drinkers need not change their drinking habits for health reasons, except in exceptional circumstances.

Understanding cognition in older patients with cancer

Cancer and neurocognitive disorders, such as dementia and delirium, are common and serious diseases in the elderly that are accompanied by high degree of morbidity and mortality. Furthermore, evidence supports the under-diagnosis of both dementia and delirium in older adults. Complex questions exist regarding the interaction of dementia and delirium with cancer, beginning with guidelines on how best measure disease severity, the optimal screening test for either disorder, the appropriate level of intervention in the setting of abnormal findings, and strategies aimed at preventing the development or progression of either process. Ethical concerns emerge in the research setting, pertaining to the detection of cognitive dysfunction in participants, validity of consent, disclosure of abnormal results if screening is pursued, and recommended level of intervention by investigators. Furthermore, understanding the ways in which comorbid cognitive dysfunction and cancer impact both cancer and non-cancer-related outcomes is essential in guiding treatment decisions. In the following article, we will discuss what is presently known of the interactions of pre-existing cognitive impairment and delirium with cancer. We will also discuss identified deficits in our knowledge base, and propose ways in which innovative research may address these gaps.

Dementia and Comorbidities: An Overview of Diagnosis and Management

The term “dementia” describes various neurodegenerative disorders that effect cognition, including Alzheimer disease, vascular dementia, and others. This article reviews the diagnosis and management of common types of dementia and comorbidities. Dementias are differentiated clinically by history, symptom presentation, and exclusion of other causes through laboratory and imaging studies. Cholinesterase inhibitors are useful but may not be effective for all types of dementia and provide only modest benefits. Certain medical comorbidities may increase the risk of dementia, although genetics are also important in its etiology. Psychiatric comorbidities in dementia include delirium, which is treated primarily by addressing underlying medical disorders, but antipsychotics can be useful for symptom management and patient comfort. Nonpharmacologic interventions are first-line treatments for other psychiatric comorbidities, although drug therapy may be useful in some cases. The management of patients with dementia presents many challenges and will continue to do so unless agents with pronounced disease-modifying capabilities are developed.

Genetic Determinants of Survival in Patientswith Alzheimer’s Disease

There is a strong genetic basis for late-onset of Alzheimer’s disease (LOAD), and thus far >20 genes/loci have been identified that affect the risk of LOAD. In addition to disease risk, genetic variation at these loci may also affect components of the natural history of AD, such as survival in AD. In this study, we first examined the role of known LOAD genes with survival time in 983 AD patients. We then performed genome-wide single-nucleotide polymorphism (SNP) and gene-based association analyses to identify novel loci that may influence survival of AD. Survival analysis was conducted using Cox proportional hazards regression under an additive genetics model. We found multiple nominally significant associations (p < 0.01) either within or adjacent to known LOAD genes. Genome-wide SNP analysis identified multiple suggestive novel loci and two of them were also significant in gene-based analysis (CCDC85C and NARS2) that survived after controlling for false-discovery rate at 0.05. In summary, we have identified two novel genes for survival in AD that need to be replicated in independent samples. Our findings highlight the importance of focusing on AD-related phenotypes that may help to identify additional genes relevant toAD.

Development of an oncological-multidimensional prognostic index (Onco-MPI) for mortality prediction in older cancer patients

Purpose

A multidimensional prognostic index (MPI) based on a comprehensive geriatric assessment (CGA) has been developed and validated in independent cohorts of older patients demonstrating good accuracy in predicting one-year mortality. The aim of this study was to develop a cancer-specific modified MPI (Onco-MPI) for mortality prediction in older cancer patients.

Methods

We enrolled 658 new cancer subjects ≥70 years (mean age 77.1 years, 433 females, 65.8 %) attending oncological outpatient services from September 2004 to June 2011. The Onco-MPI was calculated according to a validated algorithm as a weighted linear combination of the following CGA domains: age, sex, basal and instrumental activities of daily living, Eastern Cooperative Oncology Group performance status, mini-mental state examination, body mass index, Cumulative Illness Rating Scale, number of drugs and the presence of caregiver. Cancer sites (breast 46.5 %, colorectal 21.3 %, lung 6.4 %, prostate 5.5 %, urinary tract 5.0 %, other 15.3 %) and cancer stages (I 37 %, II 22 %, III 19 %, IV 22 %) were also included in the model. All-cause mortality was recorded. Three grades of severity of the Onco-MPI score (low risk: 0.0–0.46, medium risk: 0.47–0.63, high risk: 0.64–1.0) were calculated using RECPAM method. Discriminatory power and calibration were assessed by estimating survival C-indices, along with 95 % confidence interval (CI) and the survival-based Hosmer–Lemeshow (HL) measures.

Results

One-year mortality incidence rate was 17.4 %. A significant difference in mortality rates was observed in Onco-MPI low risk compared to medium- and high-risk patients (2.1 vs. 17.7 vs. 80.8 %, p < 0.0001). The discriminatory power of one-year mortality prediction of the Onco-MPI was very good (survival C-index 0.87, 95 % CI 0.84–0.90) with an excellent calibration (HL p value 0.854).

Conclusion

Onco-MPI appears to be a highly accurate and well-calibrated predictive tool for one-year mortality in older cancer patients that can be useful for clinical decision making in this age group.

Hospitalization risk according to geriatric assessment and laboratory parameters in elderly hematologic cancer patients

BACKGROUND

Utilizing geriatric screening tools for the identification of vulnerable older patients with cancer is important. The aim of this study is to evaluate the hospitalization risk of elderly hematologic cancer patients based on geriatric assessment and laboratory parameters.

MATERIALS AND METHODS

In this cross sectional study 61 patients with hematologic malignancies, age 65 years and older, were assessed at a hematology outpatient clinic. Standard geriatric screening tests; activities of daily living (ADL), instrumental activities of daily living (IADL), Mini Nutritional Assessment (MNA), Mini Mental State Examination (MMSE), timed up and go test (TUG), geriatrics depression scale (GDS) were administered. Demographic and medical data were obtained from patient medical records. The number of hospitalizations in the following six months was then recorded to allow analysis of associations with geriatric assessment tools and laboratory parameters.

RESULTS

The median age of the patients, 37 being males, was 66 years. Positive TUG test and declined ADL was found as significant risk factors for hospitalization (p=0.028 and p=0.015 respectively). Correlations of hospitalization with thrombocytopenia, vitamin B12 and folic acid deficiency were statistically significant (p=0.004, p=0.011 and p=0.05 respectively).

CONCLUSIONS

In this study, geriatric conditions which are usually unrecognized in a regular oncology office visit were identified. Our study indicates TUG and ADL might be use as predictive tests for hospitalization in elderly oncology populations. Also thrombocytopenia, and vitamin B12 and folic acid deficiencies are among the risk factors for hospitalization. The importance of vitamin B12 and folic acid vitamin replacement should not be underestimated in this population.

The perseverance time of informal carers for people with dementia: results of a two-year longitudinal follow-up study

Background

Given the projected increase of people with dementia over the next few decades and the related demand for informal care, an important question for health policy makers is to what extent and for how long informal carers can be expected to provide care in a sustainable way. This study aimed to investigate the perseverance time of informal carers for people with dementia.

Methods

A 2-year longitudinal cohort study was conducted. Questionnaires were used to collect data about the care situation, the impact of caregiving on carers and their need for support, and the anticipated and realized perseverance time of informal carers for people with dementia living at home. The data were analysed using bivariate and multivariate analyses.

Results

Two hundred twenty-three carers for people with dementia were included in the study and 25 (11.2 %) dropped out during the follow-up. The results show that after 1 year, 74 (37.4 %) of 198 patients were still living at home, and after 2 years, 44 (22.2 %) patients were still living at home. The variables that were associated with this outcome were identified. When informal carers anticipated that their perseverance time would be less than 1 year, this was indicative of their actual perseverance time.

Conclusions

Anticipated perseverance time provides a fair indication of the actual duration of informal care. It is most accurate when carers anticipate a limited rather than an unlimited perseverance time. Although further research is required to support these findings, the concept of perseverance time may be considered a useful additional instrument in health policy and clinical practice for monitoring carers’ need for support and for planning the transition of care from home to a nursing home.

Prognosis of patients with dementia: results from a prospective nationwide registry linkage study in the Netherlands

OBJECTIVE

To report mortality risks of dementia based on national hospital registry data, and to put these risks into perspective by comparing them with those in the general population and following cardiovascular diseases.

DESIGN

Prospective cohort study from 1 January 2000 through 31 December 2010.

SETTING

Hospital-based cohort.

PARTICIPANTS

A nationwide hospital-based cohort of 59,201 patients with clinical diagnosis of dementia (admitted to a hospital or visiting a day clinic) was constructed (38.7% men, 81.4 years (SD 7.0)).

MAIN OUTCOMES AND MEASURES

1-year and 5-year age-specific and sex-specific mortality risks were reported for patients with dementia visiting a day clinic compared with the general population; for patients hospitalised with dementia compared with patients hospitalised for acute myocardial infarction (AMI), heart failure or stroke, these were presented as absolute and relative risks (RRs).

RESULTS

1-year mortality was 38.3% in men and 30.5% in women. 5-year risk was 65.4% and 58.5%, respectively. Mortality risks were significantly higher in patients with dementia admitted to the hospital than in those visiting a day clinic (1-year RR 3.29, 95% CI 3.16 to 3.42; and 5-year RR 1.79, 95% CI 1.76 to 1.83). Compared with the general population, mortality risks were significantly higher among patients visiting a day clinic (1-year RR for women 2.99, 95% CI 2.84 to 3.14; and for men 3.94, 95% CI 3.74 to 4.16). 5-year RRs were somewhat lower, but still significant. Results were more pronounced at younger ages. Mortality risks among admitted patients were comparable or even exceeded those of cardiovascular diseases (1-year RR for women with dementia vs AMI 1.24, 95% CI 1.19 to 1.29; vs heart failure 1.05, 95% CI 1.02 to 1.08; vs stroke 1.07, 95% CI 1.04 to 1.10). 5-year RRs were comparable. For men, RRs were slightly higher.

CONCLUSIONS

Dementia has a poor prognosis as compared with other diseases and the general population. The risks among admitted patients even exceeded those following cardiovascular diseases.