Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease

Characteristics of Activities for Persons With Dementia at the Mild, Moderate, and Severe Stages

Purpose

To understand activity in dementia care, we examine relationships of disease stage with types and characteristics of meaningful activities (cueing needs, help with initiation, and recommended engagement time) provided in a home-based intervention trial designed to reduce behavioral symptoms.

Design and Methods

Data involved 158 activity prescriptions or written documents detailing prescribed activities, cueing needs, and engagement goals designed by occupational therapists for 56 families. Activities were categorized as arts and crafts, exercise/physical, cognitive, music/entertainment, manipulation/sensory/sorting, family/social/ reminiscence, and domestic/homemaking. Bivariate correlations examined relationships of activity categories and characteristics with disease stage (mild, moderate, or severe). Kruskal-Wallis H tests examined differences among disease stages and frequency of type of activities prescribed, recommended cues, and engagement time. For significant Kruskal-Wallis tests, pairwise comparisons utilized the Mann-Whitney U test.

Results

Activity categories and instructions for set up were significantly related to cognitive and functional levels. Persons with mild dementia were most often prescribed complex arts and crafts and cognitive activities. Persons with moderate dementia were most often prescribed music/entertainment. Persons with severe dementia were most often prescribed simple physical exercises and manipulation/sensory/sorting activities. Average time prescribed for activities was less for those in severe (15min) versus moderate (24min) and mild (28min) stages. The severe group required more assistance with activity initiation and cueing/redirection.

Implications

Type of activity, recommended cueing, and engagement time differed by dementia stage. Findings provide guidance as to how to use and set up activities across the dementia trajectory.

Pharmacotherapy for Dementia: A Practical Approach to the Use of Cholinesterase Inhibitors and Memantine

Cholinesterase inhibitors and memantine are the only classes of drugs approved for the treatment of dementia due to Alzheimer's disease. This article provides evidence-based recommendations to address the issues regarding the use of cholinesterase inhibitors and memantine in clinical practice. It includes their efficacy, timing, assessment, use in institutionalized patients, combined use, and use in other dementia types. However, most of the studies are of short duration (<1 year) and are mainly focused on cognitive and global improvement, whereas the practical issue of their use in daily practice such as optimal duration of treatment, long-term efficacy and delaying institutionalization are limited.

Testing the Benefits of Cognitive Training vs. Cognitive Stimulation in Mild Alzheimer's Disease: A Randomised Controlled Trial

Purpose: To undertake a randomised controlled trial to test the benefits of cognitive training (CT) vs. cognitive stimulation (CS) on general cognitive function and memory in mild Alzheimer's disease (mAD).

Method: A consecutive series of 55 mAD outpatients was randomly allocated to one of the three conditions, namely two experimental interventions (CT and CS; 17 participants each) and a control dementia (no intervention) group (CD; 21 participants). Participants in the experimental conditions received a 4-month individual intervention programme.

Results: The participants in the CT condition demonstrated a large improvement in general cognitive state with moderate gains in areas of memory targeted by the intervention (semantic memory, naming and retrieval ability) 12 months after baseline measurement compared to the other two conditions. In addition, CT seemed to generalise the other cognitive abilities that were not directly targeted with small gains noted in other domains of cognition (prospective memory, face recognition, name a person) compared to CS and CD. Participants in both the CS and CD conditions showed significant general cognitive decline, even though CS was found to ameliorate the trajectory of this decline.

Psychosocial and Environmental Treatment Approaches for Behavioral and Psychological Symptoms in Neurocognitive Disorders: an Update and Future Directions

Nearly all persons with dementia will exhibit behavioral and psychological symptoms (BPSD) at some point during the course of the disease. These symptoms often pose significant challenges for formal and informal caregivers, and their treatment is unclear. Current guidelines recommend implementing nonpharmacological interventions as the first-line approach to managing BPSD. Given the recent proliferation of research evaluating the use of nonpharmacological interventions for BPSD, there is a continuing need to reevaluate and synthesize the findings in this area. The current review examines the evidence for using psychosocial and environmental strategies, focusing on the past 3 years of research efforts and assessing how this research augments what is known from prior reviews. We conclude that the results in the recent literature concerning the efficacy of psychosocial and environmental treatment approaches to behavioral symptoms in dementia continue to be promising, yet results are also mixed. We recommend the consideration of music therapy and tailored activities when utilizing a nonpharmacological approach, as these appear particularly promising throughout the literature. We also find that multisensory stimulation and animal-assisted therapy warrant further evaluation. In contrast, in this and previous reviews, approaches such as bright light therapy and aromatherapy have consistently been shown to be ineffective and, thus, cannot be recommended with confidence based on the evidence. We discuss limitations of current research studies and make recommendations for future research in the area of psychosocial and environmental interventions for BPSD.

An evaluation of the CARES® Dementia Basics Program among caregivers

BACKGROUND

In 2014, the state of Oregon established Oregon Care Partners to provide high quality, free training to all dementia caregivers. This study evaluated participants' changes in knowledge, sense of competency in dementia caregiving, and ability to identify person-centered caregiving techniques after completing CARES® Dementia Basics online program, one of the educational resources available through this initiative.

METHODS

A convenience sample of informal and formal caregivers (N = 51) provided data at three points in time; pre-test, post-test, and a follow-up test after an additional 30-day period to determine sustained changes in knowledge, sense of competency, and person-centered care.

RESULTS

From pre-test to post-test, modest improvements were detected in sense of competence in performing dementia care (ps < 0.01) and dementia-based knowledge, F(2, 150) = 7.71, p < 0.001, a multivariate effect size of w 2 = 0.09. Even though improvements in sense of competency were not universal, three out of five individual items demonstrated positive growth from pre-test to post-test as well as four out of the five items from pre-test to follow-up test. Importantly, gains observed in dementia-based knowledge from pre-test to post-test were largely maintained at the 30-day follow-up. No significant changes were found in the correct identification of person-centered techniques after the training F(5, 150) = 1.63, p = 0.19.

CONCLUSIONS

Future research should investigate how best to maintain educational interventions within the caregiving environment and to assess subsequent skill change.

Managing behavioral disturbances in a patient with dementia

A 92-year-old patient with Parkinson disease and dementia provides an opportunity for the advanced practice registered nurse to shift thinking about behavioral disturbances in dementia, away from controlling behavior with pharmacologic approaches, such as antipsychotics, toward understanding behavior by applying the nonpharmacologic Describe, Investigate, Create, and Evaluate method.

Driving in Early-Stage Alzheimer's Disease: An Integrative Review of the Literature

One of the most difficult decisions for individuals with Alzheimer's disease (AD) is when to stop driving. Because driving is a fundamental activity linked to socialization, independent functioning, and well-being, making the decision to stop driving is not easy. Cognitive decline in older adults can lead to getting lost while driving, difficulty detecting and avoiding hazards, as well as increased errors while driving due to compromised judgment and difficulty in making decisions. The purpose of the current literature review was to synthesize evidence regarding how individuals with early-stage AD, their families, and providers make determinations about driving safety, interventions to increase driving safety, and methods to assist cessation and coping for individuals with early-stage AD. The evidence shows that changes in driving ability start early and progress throughout the trajectory of AD. Some individuals with mild cognitive impairment or early-stage AD may be safe to drive for a period of time. Support groups aimed at helping with the transition have been shown to be helpful for individuals who stop driving. Research and practice must support interventions to help individuals maintain safety while driving, as well as cope with driving cessation. [Res Gerontol Nurs. 2017; 10(2):86-100.].

Exploring the prevalence and variance of cognitive impairment, pain, neuropsychiatric symptoms and ADL dependency among persons living in nursing homes; a cross-sectional study

BACKGROUND

Earlier studies in nursing homes show a high prevalence of cognitive impairment, dependency in activities of daily living (ADL), pain, and neuropsychiatric symptoms among residents. The aim of this study was to explore the prevalence of the above among residents in a nationally representative sample of Swedish nursing homes, and to investigate whether pain and neuropsychiatric symptoms differ in relation to gender, cognitive function, ADL-capacity, type of nursing-home unit and length of stay.

METHODS

Cross-sectional data from 188 randomly selected nursing homes were collected. A total of 4831 residents were assessed for cognitive and ADL function, pain and neuropsychiatric symptoms. Data were analysed using descriptive statistics and the chi-square test.

RESULTS

The results show the following: the prevalence of cognitive impairment was 67 %, 56 % of residents were ADL-dependent, 48 % exhibited pain and 92 % exhibited neuropsychiatric symptoms. The prevalence of pain did not differ significantly between male and female residents, but pain was more prevalent among cognitively impaired and ADL-dependent residents. Pain prevalence was not significantly different between residents in special care units for people with dementia (SCU) and general units, or between shorter-and longer-stay residents. Furthermore, the prevalence of neuropsychiatric symptoms did not differ significantly between male and female residents, between ADL capacities or in relation to length of stay. However, residents with cognitive impairment and residents in SCUs had a significantly higher prevalence of neuropsychiatric symptoms than residents without cognitive impairment and residents in general units.

CONCLUSIONS

The prevalence rates ascertained in this study could contribute to a greater understanding of the needs of nursing-home residents, and may provide nursing home staff and managers with trustworthy assessment scales and benchmark values for further quality assessment purposes, clinical development work and initiating future nursing assessments.

Perspectives for treating Alzheimer's disease: a review on promising pharmacological substances

CONTEXT AND OBJECTIVE

Dementia is a syndrome characterized by functional and cognitive decline. Alzheimer's disease (AD) is one of the most common causes of dementia and has high prevalence among the elderly. It is known that there is no drug capable of interfering with the course of the disease. Research on treatments for AD has been marked by the appearance of new drugs and their abandonment. This study aimed to describe drugs that have been studied with regard to treating AD and which are capable of influencing the course of the disease.

DESIGN AND SETTING

Narrative review on original articles published worldwide.

METHODS

A systematized search was conducted in the PubMed/MEDLINE, Cochrane Library/Cochrane and SciELO/Bireme databases. The descriptors "Molecular Mechanisms of Pharmacological Action" and "Drug Therapy" were each combined with the descriptor "Alzheimer disease". All of these can be found in MeSH and DeCS. These descriptors were used alone or in combination, and a filter specifying publication between January 2009 and October 2015 in English, Spanish or Portuguese was set.

RESULTS

6,888 articles were found, of which 37 were included in this review; 70.3% of the articles selected were of good quality with low or unclear risk of bias. 86 drugs were considered promising for AD treatment and these were classified into 20 pharmacological categories.

CONCLUSION

There are no drugs capable of influencing the course of AD such that treatments are safe and effective. However, immunomodulators stood out as promising, given their effectiveness and quality in the articles analyzed.

Citalopram for the Treatment of Agitation in Alzheimer Dementia: Genetic Influences

OBJECTIVE

To assess potential genetic influences on citalopram treatment efficacy for agitation in individuals with Alzheimer dementia (AD). Six functional genetic variants were studied in the following genes: serotonin receptor 2A (HTR2A-T102C), serotonin receptor 2C (HTR2C-Cys23Ser), serotonin transporter (5HTT-LPR), brain-derived neurotropic factor (BDNF-Val66Met), apolipoprotein E (ε2, ε3, ε4 variants), and cytochrome P450 (CYP2C19). Treatment response by genotype was measured by (1) the agitation domain of the Neurobehavioral Rating Scale, (2) the modified Alzheimer Disease Cooperative Study-Clinical Global Impression of Change scale (mADCS-CGIC), (3) the agitation domain of the Neuropsychiatric Inventory (NPI), and (4) the Cohen-Mansfield Agitation Inventory.

METHOD

We utilized data from the Citalopram for Agitation in Alzheimer's Disease (CitAD) database. CitAD was a 9-week randomized, double-blind, placebo-controlled multicenter clinical trial showing significant improvement in agitation and caregiver distress in patients treated with citalopram. Proportional odds logistic regression and mixed effects models were used to examine the above-mentioned outcome measures.

RESULTS

Significant interactions were noted on the NPI agitation domain for HTR2A (likelihood ratio [LR] = 6.19, df = 2, P = .04) and the mADCS-CGIC for HTR2C (LR = 4.33, df = 2, P = .02) over 9 weeks.

DISCUSSION

Treatment outcomes in CitAD showed modest, although statistically significant, influence of genetic variation at HTR2A and HTR2C loci. Future studies should continue to examine the interaction of known genetic variants with antidepressant treatment in patients with AD having agitation.

Non-pharmacological Management of Behavioral Symptoms in Frontotemporal and Other Dementias

Worldwide prevalence of dementia is predicted to double every 20 years. The most common cause in individuals over 65 is Alzheimer's disease (AD), but in those under 65, frontotemporal dementia (FTD) is as frequent. The physical and cognitive decline that characterizes these diseases is commonly accompanied by troublesome behavioral symptoms. These behavioral symptoms contribute to significant morbidity and mortality among both patients and caregivers. Medications have been largely ineffective in managing these symptoms and carry significant adverse effects. Non-pharmacological interventions have been recommended to precede the utilization of pharmacological treatments. This article reviews the research about these interventions with special attention to the variations by etiology, especially FTD. The authors offer recommendations for improving utilization of these strategies and future research recommendations.

Progresses in treating agitation: a major clinical challenge in Alzheimer's disease

INTRODUCTION

Treatment of neuropsychiatric symptoms (NPS) represents a major clinical challenge in Alzheimer's disease (AD). Agitation and aggression are frequently seen during institutionalization and increase patient morbidity and mortality and caregiver burden. Off-label use of atypical antipsychotics for treating agitation in AD showed only modest clinical benefits, with high side-effect burden and risk of mortality. Non-pharmacological treatment approaches have become the preferred first-line option. When such treatment fails, pharmacological options are often used. Therefore, there is an urgent need to identify effective and safe pharmacological treatments for efficiently treating agitation and aggression in AD and dementia.

AREAS COVERED

Emerging evidence on the neurobiological substrates of agitation in AD has led to several recent clinical trials of repositioned and novel therapeutics for these NPS in dementia as an alternative to antipsychotics. We operated a comprehensive literature search for published articles evaluating pharmacological interventions for agitation in AD, with a review of recent clinical trials on mibampator, dextromethorphan/quinidine, cannabinoids, and citalopram.

EXPERT OPINION

Notwithstanding the renewed interest for the pharmacological treatment of agitation in AD, progresses have been limited. A small number and, sometimes methodologically questionable, randomized controlled trials (RCTs) have produced disappointing results. However, recently completed RCTs on novel or repositioned drugs (mibampator, dextromethorphan/quinidine, cannabinoids, and citalopram) showed some promise in treating agitation in AD, but still with safety concerns. Further evidence will come from ongoing Phase II and III trials on promising novel drugs for treating these distressing symptoms in patients with AD and dementia.

Redesigning systems of care for older adults with Alzheimer's disease

Best-practice models of dementia care have evolved from strategies focused on family caregivers to guidelines predicated on supporting the patient-caregiver dyad along the care continuum. These models have grown in complexity to encompass medical and team-based care that is designed to coordinate dementia care across settings and providers for a defined population of patients. Although there is evidence that the models can improve outcomes, they have not been widely adopted. Barriers to the models' increased adoption include workforce limitations, the cost of necessary practice redesign, and limited evidence of their potential cost-effectiveness. We summarize the origins, evidence base, and common components of best-practice models of dementia care, and we discuss barriers to their implementation. We conclude by describing two current efforts to implement such models on a broad scale, supported by the Center for Medicare and Medicaid Innovation. Taken together, these models seek to demonstrate improved dementia care quality and outcomes, accompanied by cost savings, in both community-based and institutional care settings.

An integrative review: understanding driving retirement decisions for individuals living with a dementia

AIM

To synthesise primary research exploring decision making practices used to determine the time to retire from driving for individuals living with a dementia.

BACKGROUND

Driving requires complex cognitive and physical skills potentially compromised due to the progressive nature of dementia. Whilst on-road assessments are considered reliable indicators of driving capacity by clinicians, drivers with dementia disagree.

DESIGN

Integrative literature review informed by Whittemore & Knafl (2005).

DATA SOURCES

Electronic database search of Medline, CINAHL, Web of Science, Google Scholar 1997-2012; and incremental hand search.

REVIEW METHODS

Primary studies published in peer reviewed journals were appraised against quality assessment criteria using CASP methodological assessment tools.

RESULTS

A total of 43 studies were retained for synthesis. Key findings were abstracted and a themes matrix was generated to identify patterns of meaning. Six themes emerged: (i) dementia may compromise the complex task of driving; (ii) defining onset and severity of dementia is problematic; (iii) symptom progression impacts on driving skills; (iv) assessment of fitness to drive remains subjective; (v) some drivers are reluctant to accept negative assessment outcomes; and (vi) the search for effective strategies to enhance acceptance of driver retirement continues.

CONCLUSION

This integrative literature review identified a large body of knowledge exploring the issues of driving cessation for drivers with dementia. However a challenge remains for practitioners, drivers and their family carers regarding how best to address this highly emotive issue. Findings could inform a structured approach to address this sensitive topic in a timely manner.

Neuropsychiatric symptoms as predictors of progression to severe Alzheimer's dementia and death: the Cache County Dementia Progression Study

OBJECTIVE

Little is known about factors influencing the rate of progression of Alzheimer's dementia. Using data from the Cache County Dementia Progression Study, the authors examined the link between clinically significant neuropsychiatric symptoms in mild Alzheimer's dementia and progression to severe dementia or death.

METHOD

The Cache County Dementia Progression Study is a longitudinal study of dementia progression in incident cases of this condition. Survival analyses included unadjusted Kaplan-Meier plots and multivariate Cox proportional hazard models. Hazard ratio estimates controlled for age at dementia onset, dementia duration at baseline, gender, education level, General Medical Health Rating, and apolipoprotein E epsilon 4 genotype.

RESULTS

Three hundred thirty-five patients with incident Alzheimer's dementia were studied. Sixty-eight (20%) developed severe dementia over the follow-up period. Psychosis (hazard ratio=2.007), agitation/aggression (hazard ratio=2.946), and any one clinically significant neuropsychiatric symptom (domain score ≥4, hazard ratio=2.682) were associated with more rapid progression to severe dementia. Psychosis (hazard ratio=1.537), affective symptoms (hazard ratio=1.510), agitation/aggression (hazard ratio=1.942), mildly symptomatic neuropsychiatric symptoms (domain score of 1-3, hazard ratio=1.448), and clinically significant neuropsychiatric symptoms (hazard ratio=1.951) were associated with earlier death.

CONCLUSIONS

Specific neuropsychiatric symptoms are associated with shorter survival time from mild Alzheimer's dementia to severe dementia and/or death. The treatment of specific neuropsychiatric symptoms in mild Alzheimer's dementia should be examined for its potential to delay time to severe dementia or death.

Association between pain, neuropsychiatric symptoms, and physical function in dementia: a systematic review and meta-analysis

Background

Pain, neuropsychiatric symptoms (NPS) and functional impairment are prevalent in patients with dementia and pain is hypothesized to be causal in both neuropsychiatric symptoms (NPS) and functional impairment. As the exact nature of the associations is unknown, this review examines the strength of associations between pain and NPS, and pain and physical function in patients with dementia. Special attention is paid to the description of measurement instruments and the methods used to detect pain, NPS and physical function.

Methods

A systematic search was made in the databases of PubMed (Medline), Embase, Cochrane, Cinahl, PsychINFO, and Web of Science. Studies were included that described associations between pain and NPS and/or physical function in patients with moderate to severe dementia.

Results

The search yielded 22 articles describing 18 studies, including two longitudinal studies. Most evidence was found for the association between pain and depression, followed by the association between pain and agitation/aggression. The longitudinal studies reported no direct effects between pain and NPS but some indirect effects, e.g. pain through depression. Although some association was established between pain and NPS, and pain and physical function, the strength of associations was relatively weak. Interestingly, only three studies used an observer rating scale for pain-related behaviour.

Conclusions

Available evidence does not support strong associations between pain, NPS and physical function. This might be due to inadequate use or lack of rating scales to detect pain-related behaviour. These results show that the relationship between pain and NPS, as well as with physical function, is complicated and warrants additional longitudinal evaluation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0048-6) contains supplementary material, which is available to authorized users.

Longitudinal medication usage in Alzheimer disease patients

This study examined in detail patterns of cholinesterase inhibitors (ChEIs) and memantine use and explored the relationship between patient characteristics and such use. Patients with probable Alzheimer disease AD (n=201) were recruited from the Predictors Study in 3 academic AD centers and followed from early disease stages for up to 6 years. Random effects logistic regressions were used to examine effects of patient characteristics on ChEIs/memantine use over time. Independent variables included measures of function, cognition, comorbidities, the presence of extrapyramidal signs, psychotic symptoms, age, sex, and patient's living situation at each interval. Control variables included assessment interval, year of study entry, and site. During a 6-year study period, rate of ChEIs use decreased (80.6% to 73.0%) whereas memantine use increased (2.0% to 45.9%). Random effects logistic regression analyses showed that ChEI use was associated with better function, no psychotic symptoms, and younger age. Memantine use was associated with better function, poorer cognition, living at home, later assessment interval, and later year of study entry. Results suggest that high rate of ChEI use and increasing memantine use over time are consistent with current practice guidelines of initiation of ChEIs in mild-to-moderate AD patients and initiation of memantine in moderate-to-severe patients.

Medication development for agitation and aggression in Alzheimer disease: review and discussion of recent randomized clinical trial design

BACKGROUND

The management of disruptive neuropsychiatric symptom (NPS) such as agitation and aggression (A/A) is a major priority in caring for people with Alzheimer's disease (AD). Few effective pharmacological or non-pharmacological options are available. Results of randomized clinical trials (RCTs) of drugs for A/A have been disappointing. This may result from the absence of biological efficacy for medications tested in treating A/A. It may also be related to methodological issues such as the choice of outcomes. The aim of this review was to highlight key methodological issues pertaining to RCTs of current and emerging medications for the treatment of A/A in AD.

METHODS

We searched PubMed/Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for RCTs comparing medications with either placebo or other drugs in the treatment of A/A in AD, between January 2008 and December 2013.

RESULTS

We identified a total of 18 RCTs; of these, 11 were completed and 7 ongoing. Of the ongoing RCTs, only one is in Phase III. Seven of 10 completed RCTs with reported results did not report greater benefit from drug than placebo. Each of the completed RCTs used a different definition of "clinically significant A/A." There was considerable heterogeneity in study design. The primary endpoints were largely proxy-based but a variety of scales were used. The definition of caregiver and scales used to assess caregiver outcomes were similarly heterogeneous. Placebo response was notable in all trials.

CONCLUSIONS

This review highlights a great heterogeneity in RCTs design of drugs for A/A in AD and some key methodological issues such as definition of A/A, choice of outcome measures and caregiver participation that could be addressed by an expert consensus to optimize future trials design.

Late-life psychosis: diagnosis and treatment

Psychosis is one of the most common conditions in later life with a lifetime risk of 23 %. Despite its high prevalence, late-onset psychosis remains a diagnostic and treatment dilemma. There are no reliable pathognomonic signs to distinguish primary or secondary psychosis. Primary psychosis is a diagnosis of exclusion and the clinician must rule out secondary causes. Approximately 60 % of older patients with newly incident psychosis have a secondary psychosis. In this article, we review current, evidence-based diagnostic and treatment approaches for this heterogeneous condition, emphasizing a thorough evaluation for the "six d's" of late-life psychosis (delirium, disease, drugs dementia, depression, delusions). Treatment is geared towards the specific cause of psychosis and tailored based on comorbid conditions. Frequently, environmental and psychosocial interventions are first-line treatments with the judicious use of pharmacotherapy as needed. There is an enormous gap between the prevalence of psychotic disorders in older adults and the availability of evidence-based treatment. The dramatic growth in the elderly population over the first half of this century creates a compelling need to address this gap.

Tailoring the antibody response to aggregated Aß using novel Alzheimer-vaccines

Recent evidence suggests Alzheimer-Disease (AD) to be driven by aggregated Aß. Capitalizing on the mechanism of molecular mimicry and applying several selection layers, we screened peptide libraries for moieties inducing antibodies selectively reacting with Aß-aggregates. The technology identified a pool of peptide candidates; two, AFFITOPES AD01 and AD02, were assessed as vaccination antigens and compared to Aβ1-6, the targeted epitope. When conjugated to Keyhole Limpet Hemocyanin (KLH) and adjuvanted with aluminum, all three peptides induced Aß-targeting antibodies (Abs). In contrast to Aß1-6, AD01- or AD02-induced Abs were characterized by selectivity for aggregated forms of Aß and absence of reactivity with related molecules such as Amyloid Precursor Protein (APP)/ secreted APP-alpha (sAPPa). Administration of AFFITOPE-vaccines to APP-transgenic mice was found to reduce their cerebral amyloid burden, the associated neuropathological alterations and to improve their cognitive functions. Thus, the AFFITOME-technology delivers vaccines capable of inducing a distinct Ab response. Their features may be beneficial to AD-patients, a hypothesis currently tested within a phase-II-study.

From rural to urban areas: differences in behavioural and psychological symptoms of dementia in nursing home residents according to geographical location

BACKGROUND

We determined whether the prevalence of behavioural and psychological symptoms of dementia (BPSD) in institutionalized older adults differed according to the geographical location of different facilities.

METHODS

This cross-sectional study covered 175 nursing homes (NH) in France (n = 6275; age, 86.0 ± 8.2 years; women, 73.7%). Information on NH residents' health status and NH structure and internal organization were recorded by the NH staff. Each participant was coded for the presence or absence of the following BPSD: aggressive, screaming, and wandering behaviours. NH were geographically defined as rural (<2000 inhabitants), low urban (2000 ≤ inhabitants < 10 000), intermediate urban (10 000 ≤ inhabitants < 100 000), or high urban (inhabitants ≥ 100 000).

RESULTS

Adjusted binary logistic regressions showed that, compared with residents living in rural NH, those living in NH located in high-urban areas had a significantly higher risk of aggressiveness (odds ratio = 1.33; 95% confidence interval = 1.06-1.67) and screaming (odds ratio = 1.43; 95% confidence interval = 1.05-1.95). The likelihood of aggressiveness was also higher in residents living in NH located in intermediate-urban areas (odds ratio = 1.36; 95% confidence interval = 1.13-1.65).

CONCLUSIONS

Rurality seems to play a positive role in the expression of BPSD. If this hypothesis were confirmed, it would encourage NH staff to develop activities that explore rural potentials for the management of BPSD.

Management of Behavioral and Psychological Symptoms of Dementia

Symptoms of disturbed perception, thought content, mood, or behavior that frequently occur in patients with dementia are defined as the term "Behavioral and Psychological Symptoms of Dementia (BPSD)." The behavioral symptoms of dementia include physical/verbal aggression, agitation, disinhibition, restlessness, wandering, culturally inappropriate behaviors, sexual disinhibition, and hoarding, and the psychological symptoms of dementia are anxiety, depressive mood, hallucinations and delusions, apathy, and misidentification syndrome. With the cognitive decline in Alzheimer's Dementia (AD), the frequency of neuropsychiatric symptoms increases. Apathy, depression, irritability, agitation, and anxiety are the most frequently detected neuropsychiatric symptoms of AD. In the mild stage of AD, affective symptoms are more likely to occur; agitated and psychotic behaviors are frequent in patients with moderately impaired cognitive function. When neuropsychiatric symptoms are first detected, medical conditions, such as delirium, infection, dehydration, diarrhea, and drug interactions, must be ruled out. The treatment of mild BPSD must be started with psychosocial approaches, such as behavioral management, caregiver education, and physical activity. Medications are indicated for BPSD symptoms that are refractory to non-pharmacological interventions or severe or jeopardizing the safety of a patient or others, often in conjunction with non-pharmacological interventions.

Assessing neuropsychiatric symptoms in people with dementia: a systematic review of measures

BACKGROUND

Neuropsychiatric symptoms (NPS) occur in people with dementia throughout disease course and across etiologies. NPS are associated with significant morbidities and hastened disease processes. Nevertheless, people with dementia are not systematically assessed for NPS in clinical settings. We review existing NPS measures for clinical and/or research purposes, and identify measurement gaps.

METHODS

We conducted a computerized search of peer-reviewed published studies of measures (January 1, 1980-December 1, 2013) using multiple search terms. Measures selected for review were in English, had adequate psychometric properties, and were developed for or used with people with dementia. Papers describing measures were evaluated by three coders along seven characteristics: behavioral domains, number of items, method of administration, response categories, targeted population, setting, and psychometric properties.

RESULTS

Overall, 2,233 papers were identified through search terms, and 36 papers from manual searches of references. From 2,269 papers, 85 measures were identified of which 45 (52.9%) had adequate psychometric properties and were developed or used with dementia populations. Of these, 16 (35.6%) were general measures that included a wide range of behaviors; 29 (64.4%) targeted specific behaviors (e.g. agitation). Measures differed widely as to behaviors assessed and measurement properties.

CONCLUSIONS

A robust set of diverse measures exists for assessing NPS in different settings. No measures identify risk factors for behaviors or enable an evaluation of the context in which behaviors occur. To improve clinical efforts, research is needed to evaluate concordance of behavioral ratings between formal and informal caregivers, and to develop and test measures that can identify known risks for behaviors and the circumstances under which behaviors occur.

Cognitive and neuropsychiatric impairments in Alzheimer's disease: current treatment strategies

This update on Alzheimer's disease (AD) discusses treatment strategies for cognitive and neuropsychiatric symptoms (such as agitation, psychosis, anxiety, and depression) common in this illness, emphasizing in particular nonpharmacologic strategies such as cognitive interventions, physical exercise, and psychotherapy. We provide an overview of cognitive enhancers and their combination strategies and medications commonly used for treatment of neuropsychiatric symptoms in AD. Finally, we give recommendations for providing support to caregivers and suggest how to identify caregiver/patient pairs most in need of intensive dementia care services.

Associated factors with antipsychotic use in long-term institutional care in eight European countries: Results from the RightTimePlaceCare study

OBJECTIVES

To determine factors associated with the antipsychotic (AP) prescription for people with dementia (PwD) recently admitted to institutional long-term care facilities (LTCFs) and to ascertain differences in the use of this medication in 8 European countries.

DESIGN

An exploratory cross-sectional study.

SETTING

LTCFs from 8 European countries (Estonia, Finland, France, Germany, The Netherlands, Spain, Sweden, and England).

PARTICIPANTS

A total of 791 PwD recently admitted to an LTCF and their caregivers.

MEASUREMENTS

Baseline data from RightTimePlaceCare survey was used. Patients' medical conditions, neuropsychiatric symptoms, physical and cognitive status, and medications were recorded. Multiple logistic regression models were used to assess associations with the AP use.

RESULTS

A group of 296 patients (37.4%) of 791 patients recently admitted received AP medication. The prevalence of the use of 1 or more APs varied between study countries, ranging from 12% in Sweden to 54% in Spain. Factors independently associated with the AP use were living in Sweden [odds ratio (OR) 0.12, 95% confidence interval (CI) 0.05-0.30], Finland (OR 0.26, 95% CI 0.14-0.48), Germany (OR 2.75, 95% CI 1.55-4.86) and Estonia (OR 6.79, 95% CI 3.84-12.0). The odds of AP use decreased with the presence of a dementia specific unit in the LTCF (OR 0.60, 95% CI 0.39-0.92), but was higher among residents with a hyperactivity behavior (OR 2.12, 95% CI 1.41-3.18).

CONCLUSION

The current study shows that more than one-third of the residents recently admitted received APs and that prescription frequency across countries varied significantly. This study raises the possibility that the presence of a dementia-specific unit might play a role in the AP use. Further studies should investigate this association and seek better understanding of what will achieve optimal quality of AP use among newly admitted residents in LTCF.

Common psychiatric problems in cognitively impaired older patients: causes and management

Although dementias are defined by their cognitive and functional deficits, psychiatric problems are common, contribute to patient distress and caregiver burden, and precipitate institutionalization. Successful treatment involves understanding that physiologic, psychological, and environmental factors can contribute to the development of these symptoms. By carefully assessing each of these factors, clinicians can individualize treatment and flexibly use nonpharmacologic and pharmacologic approaches tailored to patients and the context of care. Although there exist limitations to many treatment options, clinicians can still adapt current knowledge to develop a multifaceted treatment approach that improves the quality of life for patients and their caregivers.

Reactions and Interventions for Delusions in Nursing Home Residents with Dementia

This is a qualitative and quantitative study examining institutional staff members' reactions to delusions experienced by nursing home residents. Participants were 38 nursing home residents aged 65 and older, diagnosed with dementia. Data were collected from 8 nursing homes in Israel between June 2007 and January 2009. Assessments included Behavioral Pathology in Alzheimer's Disease Rating Scale, Neuropsychiatric Inventory: Nursing Home version, Etiological Assessment of Psychotic Symptoms In Dementia, Activities of Daily Living, and Mini-Mental State Examination. A wide variety of interventions with dementia-related symptoms was found to be effective to varying degrees. This included general approaches for a variety of symptoms as well as symptom-specific interventions. Caregivers do not always seem to be aware that multiple approaches are available to them when dealing with dementia. The most effective approaches may be those tailored to the individual. Combining interventions may increase overall effectiveness. Caregiver's experience and the institutional culture may affect the choice of intervention used, either positively or negatively.

Implications of a longitudinal cognitive intervention program in mild Alzheimer's disease

The implications of a longitudinal (5 years) intervention program in a mild Alzheimer's disease (mAD) patient targeting mainly the language deficits were investigated. The program had 2 parts: the intensive one included training strategies and tasks that enhanced his impairments (memory, naming, comprehension), and the second one (the next 4 years), without guidelines or teaching. The first follow up (11 months later) showed significant improvements to memory, categorical verbal fluency, comprehension and written narrative ability even to untrained functions (behavior and functional ability). The second follow up (5 years later) showed retained improvement to delayed memory tasks, language and general cognitive state. Long life cognitive programs retrograde the mAD and seem to maintain the independence of the patient and make remote the possibility of the institutionalization.

A multidimensional home-based care coordination intervention for elders with memory disorders: the maximizing independence at home (MIND) pilot randomized trial

OBJECTIVES

To assess whether a dementia care coordination intervention delays time to transition from home and reduces unmet needs in elders with memory disorders.

DESIGN

18-month randomized controlled trial of 303 community-living elders.

SETTING

28 postal code areas of Baltimore, MD.

PARTICIPANTS

Age 70+ years, with a cognitive disorder, community-living, English-speaking, and having a study partner available.

INTERVENTION

18-month care coordination intervention to systematically identify and address dementia-related care needs through individualized care planning; referral and linkage to services; provision of dementia education and skill-building strategies; and care monitoring by an interdisciplinary team.

MEASUREMENTS

Primary outcomes were time to transfer from home and total percent of unmet care needs at 18 months.

RESULTS

Intervention participants had a significant delay in time to all-cause transition from home and the adjusted hazard of leaving the home was decreased by 37% (Hazard ratio: 0.63, 95% Confidence Interval: 0.42-0.94) compared with control participants. Although there was no significant group difference in reduction of total percent of unmet needs from baseline to 18 months, the intervention group had significant reductions in the proportion of unmet needs in safety and legal/advance care domains relative to controls. Intervention participants had a significant improvement in self-reported quality of life (QOL) relative to control participants. No group differences were found in proxy-rated QOL, neuropsychiatric symptoms, or depression.

CONCLUSIONS

A home-based dementia care coordination intervention delivered by non-clinical community workers trained and overseen by geriatric clinicians led to delays in transition from home, reduced unmet needs, and improved self-reported QOL.

Factors associated with caregiver readiness to use nonpharmacologic strategies to manage dementia-related behavioral symptoms

BACKGROUND

Nonpharmacologic strategies to manage dementia-related behavioral symptoms depend upon caregiver implementation. Caregivers may vary in readiness to use strategies. We examined characteristics associated with readiness, extent readiness changed during intervention, and predictors of change in readiness.

METHODS

Data came from a randomized trial involving 119 caregivers in a nonpharmacologic intervention for managing behavioral symptoms. Baseline measures included caregiver, patient, and treatment-related factors. At initial (2 weeks from baseline) and final (16 weeks) intervention sessions, interventionists rated caregiver readiness as pre-action (precontemplation = 1; contemplation = 2; preparation = 3) or action (= 4). Ordinal logistic regression identified baseline characteristics associated with initial readiness. Mc Nemar-Bowker test of symmetry described change in readiness; binary logistic regression identified baseline predictors of change in readiness (initial to final sessions). One-way multivariate analysis of variance identified treatment factors (dose/intensity, number of strategies used, perceived benefits, and therapeutic engagement) associated with change in readiness.

RESULTS

At initial intervention session, 67.2% (N = 80) of caregivers were in pre-action and 32.8% (N = 39) in action. Initial high readiness was associated with better caregiver mood, less financial difficulty, lower patient cognition, and more behavioral symptoms. By final session, 72% (N = 79) were in action and 28% (N = 31) in pre-action; caregivers with less financial difficulty improved in readiness (B = -0.70, p = 0.017); those in action were more therapeutically engaged (F[2,107] = 3.61, p = 0.030) and perceived greater intervention benefits (F[2, 88] = 6.06, p = 0.003).

CONCLUSION

Whereas patient and caregiver-related factors were associated with initial readiness, financial stability, therapeutic engagement, and perceived benefits enhanced probability of change. Understanding caregiver readiness and factors associated with its change may be important considerations in nonpharmacologic interventions.

Neuropsychiatric symptoms as risk factors for progression from CIND to dementia: the Cache County Study

OBJECTIVES

To examine the association of neuropsychiatric symptom (NPS) severity with risk of transition to all-cause dementia, Alzheimer disease (AD), and vascular dementia (VaD).

DESIGN

Survival analysis of time to dementia, AD, or VaD onset.

SETTING

Population-based study.

PARTICIPANTS

230 participants diagnosed with cognitive impairment, no dementia (CIND) from the Cache County Study of Memory Health and Aging were followed for a mean of 3.3 years.

MEASUREMENTS

The Neuropsychiatric Inventory (NPI) was used to quantify the presence, frequency, and severity of NPS. Chi-squared statistics, t-tests, and Cox proportional hazard ratios were used to assess associations.

RESULTS

The conversion rate from CIND to all-cause dementia was 12% per year, with risk factors including an APOE ε4 allele, lower Mini-Mental State Examination, lower 3MS, and higher CDR sum-of-boxes. The presence of at least one NPS was a risk factor for all-cause dementia, as was the presence of NPS with mild severity. Nighttime behaviors were a risk factor for all-cause dementia and of AD, whereas hallucinations were a risk factor for VaD.

CONCLUSIONS

These data confirm that NPS are risk factors for conversion from CIND to dementia. Of special interest is that even NPS of mild severity are a risk for all-cause dementia or AD.

Risk factors for the progression of mild cognitive impairment to dementia

The increasing prevalence of cognitive impairment among the older adult population warrants attention to the identification of practices that may minimize the progression of early forms of cognitive impairment, including the transitional stage of mild cognitive impairment (MCI), to permanent stages of dementia. This article identifies both markers of disease progress and risk factors linked to the progression of MCI to dementia. Potentially modifiable risk factors may offer researchers a point of intervention to modify the effect of the risk factor and to minimize the future burden of dementia.

The experience of caregiving: the influence of coping strategies on behavioral and psychological symptoms in patients with Alzheimer's disease

OBJECTIVES

To determine whether caregiver coping strategies are independently associated with behavioral and psychological symptoms (BPS) in Alzheimer's disease (AD) after accounting for patient characteristics.

METHODS

Cross-sectional data analysis of 80 patients with AD and their primary caregivers. The presence of BPS was recorded using the Neuropsychiatric Inventory (NPI). The relationship between caregiver characteristics and BPS was assessed through one-way analysis of variance, two-tailed student t-tests or correlation coefficients. Multivariate linear regression was used to determine the combined effect of all caregiver factors that were significant on bivariate analysis regarding coping and BPS controlling for patient characteristics.

RESULTS

Caregivers were on average 62 years old, 77% female, and most were the children or the spouse of the patient. Over 50% had significant depression or anxiety. Patients were on average 77 years old and 62% were female, and most had moderate to severe dementia. After adjusting for patient characteristics, patients cared for by more depressed, more burdened, or those using more disengagement coping strategies showed higher NPI mean composite scores.

CONCLUSION

Coping strategies are associated with BPS regardeless of patient characteristics. Interventions to reduce BPS should focus on which psychological coping strategies caregivers use. Understanding how coping strategies influence BPS may help tailor specific interventions for caregivers.

Ashwagandha (Withania somnifera) reverses β-amyloid1-42 induced toxicity in human neuronal cells: implications in HIV-associated neurocognitive disorders (HAND)

Alzheimer's disease (AD) is characterized by progressive dysfunction of memory and higher cognitive functions with abnormal accumulation of extracellular amyloid plaques and intracellular neurofibrillary tangles throughout cortical and limbic brain regions. At present no curative treatment is available, and research focuses on drugs for slowing disease progression or providing prophylaxis. Withania somnifera (WS) also known as 'ashwagandha' is used widely in Ayurvedic medicine as a nerve tonic and memory enhancer. However, there is a paucity of data on the potential neuroprotective effects of W.somnifera against β-Amyloid (1-42)-induced neuropathogenesis. In the present study, we have tested the neuroprotective effects of methanol:Chloroform (3:1) extract of ashwagandha against β-amyloid induced toxicity and HIV-1Ba-L (clade B) infection using a human neuronal SK-N-MC cell line. Our results showed that β-amyloid induced cytotoxic effects in SK-N-MC cells as shown by decreased cell growth when tested individually. Also, confocal microscopic analysis showed decreased spine density, loss of spines and decreased dendrite diameter, total dendrite and spine area in clade B infected SK-N-MC cells compared to uninfected cells. However, when ashwagandha was added to β-amyloid treated and HIV-1 infected samples, the toxic effects were neutralized. Further, the MTT cell viability assays and the peroxisome proliferator-activated receptor-γ (PPARγ) levels supported these observations indicating the neuroprotective effect of WS root extract against β-amyloid and HIV-1Ba-L (clade B) induced neuro-pathogenesis.

Practical diagnosis and management of dementia due to Alzheimer's disease in the primary care setting: an evidence-based approach

OBJECTIVE

To review evidence-based guidance on the primary care of Alzheimer's disease and clinical research on models of primary care for Alzheimer's disease to present a practical summary for the primary care physician regarding the assessment and management of the disease.

DATA SOURCES

References were obtained via search using keywords Alzheimer's disease AND primary care OR collaborative care OR case finding OR caregivers OR guidelines. Articles were limited to English language from January 1, 1990, to January 1, 2013.

STUDY SELECTION

Articles were reviewed and selected on the basis of study quality and pertinence to this topic, covering a broad range of data and opinion across geographical regions and systems of care. The most recent published guidelines from major organizations were included.

RESULTS

Practice guidelines contained numerous points of consensus, with most advocating a central role for the primary care physician in the detection, diagnosis, and treatment of Alzheimer's disease. Review of the literature indicated that optimal medical and psychosocial care for people with Alzheimer's disease and their caregivers may be best facilitated through collaborative models of care involving the primary care physician working within a wider interdisciplinary team.

CONCLUSIONS

Evidence-based guidelines assign the primary care physician a critical role in the care of people with Alzheimer's disease. Research on models of care suggests the need for an appropriate medical/nonmedical support network to fulfill this role. Given the diversity and breadth of services required and the necessity for close coordination, nationwide implementation of team-based, collaborative care programs may represent the best option for improving care standards for patients with Alzheimer's disease.

Agitation and aggression in people with Alzheimer's disease

PURPOSE OF REVIEW

Agitation and aggression commonly arise in people with Alzheimer's disease (AD) and other dementias. They are distressing for the individual and often confer risk to them and to others, as well as raising significant clinical challenges. This review outlines the current evidence for pharmacological and nonpharmacological approaches to the treatment of agitation and aggression in these patients.

RECENT FINDINGS

There is a growing body of literature supporting the use of nonpharmacological approaches as well as the treatment of pain as a first-line management strategy prior to psychopharmacotherapy. Antipsychotic medications are most commonly prescribed to address agitation and aggression. Evidence indicates this approach results in a modest but significant improvement in aggression in the short term (6-12 weeks) although the impact on other symptoms of agitation is limited. There is less positive evidence to support their use in the longer term, and prescriptions of more than 12 weeks and longer periods of prescription are associated with cumulative risk of severe adverse events, including death. Suggested pharmacological alternatives with the most promising preliminary evidence include memantine, carbamazepine, citalopram, and prazosin, but none of these agents have sufficient evidence in treating agitation and aggression to recommend use in routine clinical practice.

SUMMARY

Currently, the best approach for managing these symptoms is within a framework of good practice that promotes prevention, monitoring and the use of nonpharmacological alternatives, with judicious short-term use of antipsychotics, when appropriate.

Management of apathy in nursing homes using a teaching program for care staff: the STIM-EHPAD study

OBJECTIVE

This study aimed to evaluate the effectiveness of a nursing home (NH) staff education to manage apathy in older individuals with a diagnosis of dementia.

METHODS

Sixteen NHs agreed to participate, and 230 demented apathetic residents were randomly assigned to the reference group (RG) or the intervention group (IG). IG received a month of weekly 4-h training. Qualitative evaluation was performed through interviews and questionnaires regarding work practices and knowledge about dementia. Quantitative evaluation was at baseline, at the end of the training program (week 4), and 3 months after the end of it with the use of the Neuropsychiatric Inventory (NPI), the Apathy Inventory, and two observation scales.

RESULTS

In the qualitative evaluation, very few staff responded to the questionnaire. Concerning the difficulty that managing residents' behavioral symptoms presented, aggressiveness was ranked as the most difficult behavior to manage and apathy as the least difficult. In the quantitative evaluation, the results are as follows. NPI: the IG scores increased from baseline to week 4 more than the RG for symptoms belonging to the affective and the psychotic NPI item subgroup. Apathy Inventory: there was a significant decrease of the emotional blunting score dimension in the IG. Group Observation Scale: significant improvement was observed for the emotional blunting dimension in the IG only.

CONCLUSIONS

Apathy is rarely identified as a problem in NH. Emotional blunting was the only dimension sensitive to change. Failure to improve residents' level of interest could be explained by the difficulties encountered in accessing information regarding the subjects' personal interests. But it remains possible to modify residents' emotional reactivity and staff's perceptions of residents' behaviors and emotions.

The efficacy and safety of newer anticonvulsants in patients with dementia

Anticonvulsants are a class of medications that have received considerable interest as possible treatments in patients with behavioural disturbances in dementia. The role of these medications for such a use remains controversial. The current paper reviews the published evidence surrounding the safety and efficacy (i.e. as a behavioural and cognitive treatment) of newer anticonvulsants in patients with dementia. A MEDLINE, International Pharmaceutical Abstracts, PsycINFO and clinicaltrials.gov search through to December 2011 was conducted for anticonvulsants that have received regulatory approval since 1996. Studies reporting behavioural or cognitive outcomes in patients with dementia were included. Nine trials involving only four medications met selection criteria and were included: levetiracetam (n = 4), oxcarbazepine (n = 1), topiramate (n = 2) and zonisamide (n = 2). Levetiracetam may have a role in the treatment of behavioural symptoms in dementia but study limitations substantially hinder the strength of such a recommendation. Oxcarbazepine and topiramate, based on limited data, do not appear to be effective treatments of behavioural symptoms in dementia. A lack of trials do not allow for conclusions to be made regarding zonisamide. From a cognitive standpoint, levetiracetam was the anticonvulsant most examined in patients with dementia, it appears to have less deleterious effects than some anticonvulsants. Limited data are available on the safety of these medications in elderly patients; however, studies completed thus far have demonstrated some adverse events that are more common or problematic with the use of these drugs in this patient population (i.e. somnolence, dizziness, hyponatraemia, weight loss).

Cognitive intervention therapy as treatment for behaviour disorders in Alzheimer disease: evidence on efficacy and neurobiological correlations

INTRODUCTION

The prevalence of behavioural and psychological symptoms (BPS) is very high among patients with Alzheimer disease (AD); more than 90% of AD patients will present such symptoms during the course of the disease. These symptoms result in poorer quality of life for both patients and caregivers and increased healthcare costs. BPS are the main factors involved in increases to the caregiver burden, and they often precipitate the admission of patients to residential care centres.

DEVELOPMENT

Current consensus holds that intervention models combining pharmacological and non-pharmacological treatments are the most effective for AD patients. Several studies have shown cholinesterase inhibitors and memantine combined with cognitive intervention therapy (CIT) to be effective for improving patients' cognitive function and functional capacity for undertaking daily life activities. However, the efficacy of CIT as a treatment for BPS has not yet been clearly established, which limits its use for this purpose in clinical practice. The objective of this review is to gather available evidence on the efficacy of cognitive intervention therapy (CIT) on BPS in patients with AD.

CONCLUSIONS

The results of this review suggest that CIT may have a beneficial effect on BPS in patients with AD and should therefore be considered a treatment option for patients with AD and BPS.

Nonpharmacologic management of behavioral symptoms in dementia

Behavioral symptoms such as repetitive speech, wandering, and sleep disturbances are a core clinical feature of Alzheimer disease and related dementias. If untreated, these behaviors can accelerate disease progression, worsen functional decline and quality of life, cause significant caregiver distress, and result in earlier nursing home placement. Systematic screening for behavioral symptoms in dementia is an important prevention strategy that facilitates early treatment of behavioral symptoms by identifying underlying causes and tailoring a treatment plan. First-line nonpharmacologic treatments are recommended because available pharmacologic treatments are only modestly effective, have notable risks, and do not effectively treat some of the behaviors that family members and caregivers find most distressing. Examples of nonpharmacologic treatments include provision of caregiver education and support, training in problem solving, and targeted therapy directed at the underlying causes for specific behaviors (eg, implementing nighttime routines to address sleep disturbances). Based on an actual case, we characterize common behavioral symptoms and describe a strategy for selecting evidence-based nonpharmacologic dementia treatments. Nonpharmacologic management of behavioral symptoms in dementia can significantly improve quality of life and patient-caregiver satisfaction.

Effects of general medical health on Alzheimer's progression: the Cache County Dementia Progression Study

BACKGROUND

Several observational studies have suggested a link between health status and rate of decline among individuals with Alzheimer's disease (AD). We sought to quantify the relationship in a population-based study of incident AD, and to compare global comorbidity ratings to counts of comorbid conditions and medications as predictors of AD progression.

METHODS

This was a case-only cohort study arising from a population-based longitudinal study of memory and aging, in Cache County, Utah. Participants comprised 335 individuals with incident AD followed for up to 11 years. Patient descriptors included sex, age, education, dementia duration at baseline, and APOE genotype. Measures of health status made at each visit included the General Medical Health Rating (GMHR), number of comorbid medical conditions, and number of non-psychiatric medications. Dementia outcomes included the Mini-Mental State Examination (MMSE), Clinical Dementia Rating - sum of boxes (CDR-sb), and the Neuropsychiatric Inventory (NPI).

RESULTS

Health status tended to fluctuate over time within individuals. None of the baseline medical variables (GMHR, comorbidities, and non-psychiatric medications) was associated with differences in rates of decline in longitudinal linear mixed effects models. Over time, low GMHR ratings, but not comorbidities or medications, were associated with poorer outcomes (MMSE: β = -1.07 p = 0.01; CDR-sb: β = 1.79 p < 0.001; NPI: β = 4.57 p = 0.01).

CONCLUSIONS

Given that time-varying GMHR, but not baseline GMHR, was associated with the outcomes, it seems likely that there is a dynamic relationship between medical and cognitive health. GMHR is a more sensitive measure of health than simple counts of comorbidities or medications. Since health status is a potentially modifiable risk factor, further study is warranted.

Solving the puzzle of Alzheimer disease

Managing patients with dementia and Alzheimer disease can be a challenge. Often, families and caregivers ask clinicians about the latest treatments. This article summarizes the latest evidence-based practice related to pharmacologic and nonpharmacologic management of patients with Alzheimer disease.