Underrecognition and undertreatment of dementia in Italian nursing homes

Delirium in long-term care and the myth of Proteus

This editorial comments on the article by Webber et al. in this issue.

The relationship between polypharmacy and physical performance in patients with early-stage Alzheimer's disease

INTRODUCTION

Our aim was to evaluate the association between polypharmacy and certain physical performance measures used to assess ambulation in early-stage Alzheimer patients.

MATERIALS AND METHODS

This cross-sectional study was conducted in the dementia outpatient clinic of a tertiary care center. The usage of five or more drugs per day was accepted as polypharmacy and patients with moderate and severe dementia were excluded. Usual gait speed (UGS), timed up and go (TUG), and chair sit-to-stand test (CSST) were applied to assess physical performance status.

RESULTS

There were 134 participants in our study (67.9% female, mean age 80.2 ± 7.9 years) and 75 (56%) patients were polypharmacy patients. The patients with polypharmacy showed poor physical performance compared to the patients without polypharmacy (UGS p = .005, TUG p < .001, CSST p < .001). The parameters that were significantly higher and more common in the polypharmacy group were body mass index (p = .026), hypertension (p = .013), diabetes mellitus (p = .018), ischemic heart disease (p < .001), atrial fibrillation (p = .030), depression (p = .012), and hypothyroidism (p = .007). In multivariate analyses, polypharmacy was independently associated with slow UGS [Odds ratio (OR) 1.248 (95%) confidence interval (CI) 1.145-1.523, p = .007]; long TUG [OR 1.410 (95%) CI 1.146-1.736, p = .001]; and long CSST [OR 1.892 (95%) CI 1.389-2.578, p < .001].

CONCLUSION

Our study demonstrated the association of polypharmacy with poor physical performance in patients with early stage Alzheimer's disease. Prospective long-term studies investigating the relationship of polypharmacy and drug subgroups with physical performance in elderly patients with Alzheimer's disease would be appropriate.

Primary care costs due to prodromal Alzheimer disease: a real-world study in patients with a 10-year or longer medical history

BACKGROUND

The aim of this study was to estimate primary care costs of prodromal signs/symptoms of Alzheimer disease (AD), during a 10-year or longer period preceding AD diagnosis, in relation to costs cumulated in the general population for the same reasons.

METHODS

Nested case-control study involving 1889 AD cases and 18,890 controls aged 60+ from the Italian primary care Health Search Database (HSD). AD incident cases were through the International Classification of Diseases, 9th edition. Costs related to drugs, diagnostic tests and specialist referrals triggered by prodromal AD signs and/or symptoms were quantified and compared with costs cumulated by non-AD counterparts.

RESULTS

During the pre-diagnosis 10-year or longer period, prodromal signs and symptoms trigger diagnostic and therapeutic costs 55% higher than those cumulated in general population for the same clinical reasons. After accounting for patients' comorbidity and regional differences, the mean cost related to diagnostic and therapeutic procedures, and those related to specialist referrals, amounted to 854.1 €(SD: 630.6 €) in AD incident cases vs. 527.3 €(SD: 446.2) cumulated in patients not developing AD.

CONCLUSION

Prodromal AD manifestations are associated with primary care costs that resulted higher than those cumulated in the general population aged 60+. It remains to be elucidated if earlier dementia diagnoses would be associated with reduced costs triggered by the same clinical signs and symptoms.

Dissecting Digital Card Games to Yield Digital Biomarkers for the Assessment of Mild Cognitive Impairment: Methodological Approach and Exploratory Study

Background

Mild cognitive impairment (MCI), the intermediate cognitive status between normal cognitive decline and pathological decline, is an important clinical construct for signaling possible prodromes of dementia. However, this condition is underdiagnosed. To assist monitoring and screening, digital biomarkers derived from commercial off-the-shelf video games may be of interest. These games maintain player engagement over a longer period of time and support longitudinal measurements of cognitive performance.

Objective

This paper aims to explore how the player actions of Klondike Solitaire relate to cognitive functions and to what extent the digital biomarkers derived from these player actions are indicative of MCI.

Methods

First, 11 experts in the domain of cognitive impairments were asked to correlate 21 player actions to 11 cognitive functions. Expert agreement was verified through intraclass correlation, based on a 2-way, fully crossed design with type consistency. On the basis of these player actions, 23 potential digital biomarkers of performance for Klondike Solitaire were defined. Next, 23 healthy participants and 23 participants living with MCI were asked to play 3 rounds of Klondike Solitaire, which took 17 minutes on average to complete. A generalized linear mixed model analysis was conducted to explore the differences in digital biomarkers between the healthy participants and those living with MCI, while controlling for age, tablet experience, and Klondike Solitaire experience.

Results

All intraclass correlations for player actions and cognitive functions scored higher than 0.75, indicating good to excellent reliability. Furthermore, all player actions had, according to the experts, at least one cognitive function that was on average moderately to strongly correlated to a cognitive function. Of the 23 potential digital biomarkers, 12 (52%) were revealed by the generalized linear mixed model analysis to have sizeable effects and significance levels. The analysis indicates sensitivity of the derived digital biomarkers to MCI.

Conclusions

Commercial off-the-shelf games such as digital card games show potential as a complementary tool for screening and monitoring cognition.

Trial Registration

ClinicalTrials.gov NCT02971124; https://clinicaltrials.gov/ct2/show/NCT02971124

Relationship between frailty and drug use among nursing homes residents: results from the SHELTER study

BACKGROUND

1.5-8% of older adults live in nursing homes (NHs), presenting a high prevalence of frailty and polypharmacy.

AIMS

To investigate the association of frailty with polypharmacy and drug prescription patterns in a sample of European Nursing Home (NH) residents.

METHODS

Cross-sectional study based on the data from the Services and Health for Elderly in Long TERm care (SHELTER) study. 4121 NH residents in Europe and Israel. Residents' clinical, cognitive, social, and physical status were evaluated with the InterRAI LTCF tool, which allows comprehensive, standardized evaluation of persons living in NH. Polypharmacy and hyperpolypharmacy were defined as the concurrent use of ≥ 5 and ≥ 10 medications. Frailty was defined according to the FRAIL-NH scale.

RESULTS

Of 4121 participants, 46.6% were frail (mean age 84.6 ± 9.2 years; 76.4% female). Polypharmacy and hyperpolypharmacy were associated with a lower likelihood of frailty (Odds Ratio = 0.72; 95% CI = 0.59-0.87 and OR = 0.75; 95% CI = 0.60-0.94, respectively). Patterns of drug prescriptions were different between frail and non-frail residents. Symptomatic drugs (laxatives, paracetamol, and opioids) were more frequently prescribed among frail residents, while preventive drugs (bisphosphonates, vitamin D, and acetylsalicylic acid) were more frequently prescribed among non-frail residents.

CONCLUSIONS

Frailty is associated with less polypharmacy and with higher prevalence of symptomatic drugs use among NH residents. Further studies are needed to define appropriateness of drug prescription in frail individuals.

Italian version of the short 10/66 dementia diagnostic schedule: a validation study

OBJECTIVES

To determine the criterion and concurrent validity of the Italian version of the short 10/66 Dementia Diagnostic Schedule and algorithm in a sample of Italian native speakers, older adults.

DESIGN

A cross-sectional, validation study.

SETTING

The study was conducted with older adults living in the community and in nursing homes in the Canton of Ticino, Switzerland, and the Piedmont region in Italy between March and August 2019.

PARTICIPANTS

A convenience sample of 229 participants (69% females) were recruited. The eligibility criteria were being ≥60 years old and having an informant. The final sample included 74 participants (32%) with a previous clinical diagnosis of dementia and 155 (68%) cognitively healthy older adults.

PRIMARY AND SECONDARY OUTCOME MEASURES

The short version of 10/66 Dementia Diagnostic Schedule consists of the Community Screening Instrument for Dementia, the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) 10-word list learning task with delayed recall and the depression scale, Euro-Depression (EURO-D) scale. Disability was measured using the WHO Disability Assessment Schedule (WHO-DAS II).

RESULTS

The Italian version of the short 10/66 Dementia Diagnostic Schedule showed fair sensitivity (87%), specificity (61%) and agreement with the clinical diagnosis of dementia (kappa=0.40, area under the receiver operating characteristics curve=0.74). Older adults with dementia living in nursing homes had higher disability scores (WHO-DAS II mean=23.14, SE=1.29) than those living in the community (WHO-DAS II mean=7.08, SE=0.66). WHO-DAS II was positively correlated with the short version of the 10/66 dementia diagnosis (β=5.23, 95% CI 2.05 to 8.41).

CONCLUSIONS

In settings where lengthy diagnostic procedures are not feasible, the short 10/66 is a practical tool to identify dementia in older adults. Our findings extend evidence on the validity of the 10/66 dementia diagnostic algorithm to high-income countries, where epidemiological evidence on dementia and its impact is outdated.

Use of Anti-Dementia Drugs Reduces the Risk of Potentially Inappropriate Medications: A Secondary Analysis of a Nationwide Survey of Prescribing Pharmacies

AIMS

As the number of older people with dementia increases, safe pharmacotherapy in this population has attracted attention in recent years. The aims of this study were to clarify the prescribing patterns in older patients who were prescribed anti-dementia drugs and to investigate the association of potentially inappropriate medications (PIMs) with the use of anti-dementia drugs.

METHODS

Adults aged ≥65 years, who were prescribed anti-dementia drugs at 585 pharmacies across Japan (N = 7,953), were surveyed. The percentage of prescriptions of anti-dementia drugs and the effect of those prescriptions on PIMs were investigated.

RESULTS

Prescriptions of anti-dementia drugs were found in 4.4% of the entire study population. A multiple logistic regression analysis revealed that the use of anti-dementia drugs reduced the risk of prescribing psychotropic drugs, which represented PIMs, and that a combination of anti-dementia drugs (e.g., cholineesterase inhibitor with memantine) may reduce the risk of prescribing PIMs compared with monotherapy.

CONCLUSION

The use of anti-dementia drugs was associated with fewer prescriptions of drugs considered as PIMs.

Underprescription of medications in older adults: causes, consequences and solutions-a narrative review

PURPOSE

Under-prescription is defined as the omission of a medication that is indicated for the treatment of a condition or a disease, without any valid reason for not prescribing it. The aim of this review is to provide an updated overview of under-prescription, summarizing the available evidence concerning its prevalence, causes, consequences and potential interventions to reduce it.

METHODS

A PubMed search was performed, using the following keywords: under-prescription; under-treatment; prescribing omission; older adults; polypharmacy; cardiovascular drugs; osteoporosis; anticoagulant. The list of articles was evaluated by two authors who selected the most relevant of them. The reference lists of retrieved articles were screened for additional pertinent studies.

RESULTS

Although several pharmacological therapies are safe and effective in older patients, under-prescription remains widespread in the older population, with a prevalence ranging from 22 to 70%. Several drugs are underused, including cardiovascular, oral anticoagulant and anti-osteoporotic drugs. Many factors are associated with under-prescription, e.g. multi-morbidity, polypharmacy, dementia, frailty, risk of adverse drug events, absence of specific clinical trials in older patients and economic factors. Under-prescription is associated with negative consequences, such as higher risk of cardiovascular events, worsening disability, hospitalization and death. The implementation of explicit criteria for under-prescription, the use of the comprehensive geriatric assessment by geriatricians, and the involvement of a clinical pharmacist seem to be promising options to reduce under-prescription.

CONCLUSION

Under-prescription remains widespread in the older population. Further studies should be performed, to provide a better comprehension of this phenomenon and to confirm the efficacy of corrective interventions.

Predictors of Functional Decline in Nursing Home Residents: The Shelter Project

BACKGROUND

The aim of our study was to identify independent predictors of functional decline in older nursing home (NH) residents, taking into account both resident and facility characteristics.

METHODS

Longitudinal observational study involving 1,760 older (≥65 y) residents of NH participating in the SHELTER* study (57 NH in eight countries). All residents underwent a comprehensive geriatric assessment using the interRAI LTCF. Functional decline was defined as an increase of at least one point in the MDS Long Form ADL scale during a 1 year follow-up. Facility and country effects were taken into account.

RESULTS

During the study period 891 (50.6%), NH residents experienced ADL decline. Residents experiencing ADL decline were older, had lower disability at baseline, were more frequently affected by severe dementia and by urinary incontinence, and used more antipsychotics. In the mixed-effect logistic regression model, factors independently associated with a higher risk of functional decline were dementia and urinary incontinence, whereas the presence of a geriatrician was a protective factor.

CONCLUSIONS

Both resident and facility characteristics are associated with the risk of functional decline in NH residents. Increasing the quality of healthcare by involving a geriatrician in residents' care might be an important strategy to improve the outcome of this vulnerable population.

Dementia Diagnoses and Treatment in Geriatric Ward Patients: A Cross-Sectional Study in Poland

Purpose

The study aimed to determine the prevalence of dementia, its types, and treatment in geriatric ward patients.

Patients and Methods

A cross-sectional study of 406 patients (77.8% women, median age 82, IQR (77-86) years) who underwent a comprehensive geriatric assessment in one of the Polish hospitals between September 2014 and April 2015 was conducted.

Results

Dementia was diagnosed in 132 (32.5%) patients (46% mixed dementia; 32% Alzheimer's disease; 10%vascular dementia; 5% dementia in Parkinson's disease; 4% frontotemporal; 3% atypical parkinsonism). A total of 95 (72%) dementia cases were not detected before, and in the above half of these patients, it was not mentioned in the referral document. Only 33.3% of dementia patients were on cognitive enhancers (donepezil, rivastigmine, or memantine); 36.4% received antipsychotics, 45.5% received anti-depressants, 25.8% received nootropics, and 16.7% received anxiolytics/hypnotics.

Discussion

The results confirmed the high incidence of underdiagnoses and undertreatment of dementia in patients admitted to the geriatric ward. It is partly due to the lack of systematic cognitive assessment in primary care settings, although other factors can play a role.

Combining diagnostic memory clinic with rehabilitation follow-up after hip fracture

PURPOSE

Cognitive impairment and dementia are common in older hip fracture patients. We describe new diagnoses of cognitive disorders (NDCDs) and associated factors in a two-year post-hip fracture follow-up including the use of the diagnostic facilities of a memory clinic.

METHODS

Data were collected on admission and at outpatient assessment 4-6 months post-hip fracture. Diagnoses of cognitive disorders followed the evidence-based Finnish national care guideline including internationally accepted criteria. NDCDs up to 2 years post-hip fracture were extracted manually from the patient files. Logistic regression models were computed to examine the associations between the pre-fracture factors and the domains of the outpatient geriatric assessment and NDCDs.

RESULTS

Of the 1165 hip fracture patients aged ≥ 65 years, 831 had no previous diagnosis of cognitive disorder. Of these, NDCD was documented in 23.3%. Alzheimer's disease (AD) with or without vascular cognitive impairment (VCI) was the most common diagnosis. Cognitive disorder was usually at a moderate stage. Age, higher ASA score and poor nutritional status on admission were associated with new cognitive disorders. At the outpatient follow-up, poorer activities of daily living and mobility disability were associated with NDCD. Patients with a NDCD were more likely to suffer greater mobility impairment, poorer nutritional status and to have more supported living arrangements at follow-up than in the pre-fracture situation.

CONCLUSION

NDCDs are common after hip fracture and associated with impaired rehabilitation outcomes and poor nutritional status. A post-hip fracture assessment co-organized in the form of a memory clinic seems to be feasible to detect previously undiagnosed cognitive disorders. Earlier diagnosis of cognitive disorders is warranted.

Simulated presence therapy for dementia

BACKGROUND

Dementia is a common and serious neuropsychiatric syndrome, characterised by progressive cognitive and functional decline. The majority of people with dementia develop behavioural disturbances, also known as behavioural and psychological symptoms of dementia (BPSD). Several non-pharmacological interventions have been evaluated to treat BPSD in people with dementia. Simulated presence therapy (SPT), an intervention that uses video or audiotape recordings of family members played to the person with dementia, is a possible approach to treat BPSD.

OBJECTIVES

To assess the effects of SPT on behavioural and psychological symptoms and quality of life in people with dementia.

SEARCH METHODS

We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), CENTRAL (The Cochrane Library) (9 April 2020), MEDLINE Ovid SP (1946 to 9 April 2020), Embase Ovid SP (1972 to 9 April 2020), PsycINFO Ovid SP (1806 to 9 April 2020), CINAHL via EBSCOhost (1980 to 9 April 2020), LILACS via BIREME (all dates to 9 April 2020), ClinicalTrials.gov (ClinicalTrials.gov) (all dates to 9 April 2020), and the World Health Organization (WHO) Portal (apps.who.int/trialsearch) (all dates to 9 April 2020). We also checked the reference lists of relevant articles to identify any additional studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials, including cross-over studies, that evaluated the efficacy of SPT, consisting of personalised audio or videotape recordings of family members, in people with any form of dementia.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed risk of bias and extracted data. No meta-analyses were conducted because of substantial heterogeneity among the included studies.

MAIN RESULTS

Three trials with 144 participants met the inclusion criteria. Two of the trials had a randomised cross-over design, one was a cross-over trial which we classified as quasi-randomised. Participants in the included studies were people with dementia living in nursing homes. They were predominantly women and had a mean age of over 80 years. SPT was performed using an audio or video recording prepared by family members or surrogates. It varied in its content, frequency of administration and duration. All the studies compared multiple treatments. In one study, SPT was compared with two other interventions; in the other two studies, it was compared with three other interventions. Specifically, SPT was compared to usual care, personalised music (two studies), a 'placebo' audiotape containing the voice of a person (two studies), and one-to-one social interaction performed by trained research assistants (one study). In terms of outcomes evaluated, one study considered agitation and withdrawn behaviour (both assessed with three methods); the second study evaluated verbal disruptive behaviour (assessed with three methods); and the third study evaluated physically agitated behaviour and verbally agitated behaviour (the method used was not clearly described). According to the GRADE criteria, the overall quality of the evidence was very low due to very small numbers of participants and risk of bias in the included studies; (none of the trials was at low risk of selection bias; all the trials were at high risk of performance bias; one trial was at high risk of attrition bias; and all had unclear selective reporting). Because of variation in the participants, the format of SPT, the comparison interventions, and the measures used to assess outcomes, we judged the results unsuitable for a meta-analysis. Within each trial, the effect of SPT on behaviour, compared to usual care, was mixed and depended on the measure used. Two trials which included a personalised music intervention reported no significant differences between simulated presence and music on behavioural outcomes. Because the overall quality of the evidence was very low, we were very uncertain regarding all the results None of the studies evaluated quality of life or any of our secondary outcome measures (performance of activities of daily living, dropout and carer burden).

AUTHORS' CONCLUSIONS

We were unable to draw any conclusions about the efficacy of SPT for treating behavioural and psychological symptoms and improving quality of life of people with dementia. New high-quality studies are needed to investigate the effect of SPT.

Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers: The IDEM Cluster Randomized Clinical Trial

IMPORTANCE

Dementia is often underdiagnosed in nursing homes (NHs). This potentially results in inappropriate care, and high rates of emergency department (ED) transfers in particular.

OBJECTIVE

To assess whether systematic dementia screening of NH residents combined with multidisciplinary team meetings resulted in a lower rate of ED transfer at 12 months compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, cluster randomized trial with NHs as the unit of randomization. The IDEM (Impact of Systematic Tracking of Dementia Cases on the Rate of Hospitalization in Emergency Care Units) trial took place at 64 public and private NHs in France. Recruitment started on May 1, 2010, and was completed on March 31, 2012. Residents who were aged 60 years or older, had no diagnosed or documented dementia, were not bedridden, had lived in the NH for at least 1 month at inclusion, and had a life expectancy greater than 12 months were included. The residents were followed up for 18 months. The main study analyses were completed on October 14, 2016.

INTERVENTION

Two parallel groups were compared: an intervention group consisting of NHs that set up 2 multidisciplinary team meetings to identify residents with dementia and to discuss an appropriate care plan, and a control group consisting of NHs that continued their usual practice. During the inclusion period of 23 months, all residents of participating NHs who met eligibility criteria were included in the study.

MAIN OUTCOMES AND MEASURES

The primary end point (ED transfer) was analyzed at 12 months, but the residents included were followed up for 18 months.

RESULTS

A total of 64 NHs participated in the study and enrolled 1428 residents (mean [SD] age, 84.7 [8.1] years; 1019 [71.3%] female): 599 in the intervention group (32 NHs) and 829 in the control group (32 NHs). The final study visit was completed by 1042 residents (73.0%). The main reason for early discontinuation was death (318 residents [22.7%]). The intervention did not reduce the risk of ED transfers during the 12-month follow-up: the proportion of residents transferred at least once to an ED during the 12-month follow-up was 16.2% in the intervention group vs 12.8% in the control group (odds ratio, 1.32; 95% CI, 0.83-2.09; P = .24).

CONCLUSIONS AND RELEVANCE

This study failed to demonstrate that systematic screening for dementia in NHs resulted in fewer ED transfers. The findings do not support implementation of multidisciplinary team meetings for systematic dementia screening of all NH residents, beyond the national recommendations for dementia diagnosis, to reduce ED transfers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01569997.

Comparison of prevalence and associated risk factors of cognitive function status among elderly between nursing homes and common communities of China: A STROBE-compliant observational study

Dementia among elderly is a serious problem worldwide. This study was conducted to estimate the prevalence and associated risk factors of dementia and mild cognitive impairment (MCI) in nursing homes (NHs) and common communities (CCs) among elderly in China.A cross-sectional survey was conducted in 4 communities across 12 cities in Southern China from May to November of 2014. Qualified psychiatrists and trained nurses carried out relevant diagnosis, assessments, interviews, and information collection. Screening test of mini-mental state examination was conducted among participants firstly, then confirmed diagnosis was carried out among the ones with positive results. Student t test, χ test, univariate, and multivariate logistic regression analysis were conducted to analyze data.A total of 2015 participants aged 65 or older were included in the final analysis; 908 came from NHs while 1107 came from CCs. The crude prevalence rates of dementia and MCI were 22.0% and 15.8%, respectively among all the participants. Dementia prevalence was 42.4% among those living in NHs, which was significantly higher than that of 5.3% in CCs (P < .0001). There were more moderate and severe dementia in NHs compared with CCs (P < .0001). It showed that older age, illiterate compared with high level of education (adjusted odds ratio, AOR = 3.32, 95% CI: 1.53-7.21), heavy drinking (AOR = 1.51 (1.00-2.24), having a medical history of diabetes (AOR = 1.41, 95% CI: 1.02-2.33), and stroke (AOR = 1.21, 95% CI: 1.01-1.23) were associated with dementia in NHs, and middle socioeconomic status might be a protective factor for dementia (AOR = 0.33, 95% CI: 0.21-0.51).The problem of senile dementia in NHs is much more serious than our estimation, and there are not enough trained nursing staffs in NHs. More population-based strategies in NHs, including conducting cognitive screening accompanied with routine physical examination among elderly population, carrying out related primary prevention policies and public health services, and paying attention to some modifiable associated risk factors such as heavy smoking and drinking are needed.

Association of frailty and cognitive impairment with benefits of oral anticoagulation in patients with atrial fibrillation

BACKGROUND

The incidence of cognitive impairment and frailty increase with age and may impact both therapy and outcomes in atrial fibrillation (AF).

METHODS

We examined the prevalence of clinically recognized cognitive impairment and frailty (as defined by the American Geriatric Society Criteria) in the Outcomes Registry for Better Informed Care in AF (ORBIT AF) and associated adjusted outcomes via multivariable Cox regression. The interaction between cognitive impairment and frailty and oral anticoagulation (OAC) in determining outcomes was examined.

RESULTS

Among 9749 patients with AF [median (IQR) age 75 (67-82) y, 57% male], cognitive impairment and frailty was identified in 293 (3.0%) and 575 (5.9%) patients respectively. Frail patients (68 vs 77%, P < .001) and those with cognitive impairment (70 vs 77%, P = .006) were both less likely to receive an OAC. Both cognitive impairment [HR (95% CI) 1.34 (1.05-1.72), P = .0198] and frailty [HR 1.29 (1.08-1.55), P = .0060] were associated with increased risk of death. Cognitive impairment and frailty were not associated with stroke/transient ischemic attack (TIA) or major bleeding. In multivariable analysis, there was no interaction between OAC use and cognitive impairment or frailty in their associations with mortality, major bleeding and a composite end point of stroke, non-central nervous system systemic embolism, TIA, myocardial infarction or cardiovascular death.

CONCLUSION

Those with cognitive impairment or frailty in AF had higher predicted risk for stroke and higher observed mortality, yet were less likely to be treated with OAC. Despite this, the benefits of OAC were similar in patients with and without cognitive impairment or frailty.

Individual risk factors for possible undetected dementia amongst community-dwelling older people in New Zealand

There is general acknowledgement of the importance of early diagnosis of dementia, yet there are still high rates of undetected dementia internationally. The aim of this cross-sectional study was to determine the sociodemographic characteristics associated with possible undetected dementia in a large sample of community-dwelling older New Zealanders. The sample consisted of older people (age ≥ 65) who had received the homecare version of the international Residential Home Care Assessment version 9.1 over a two-year period and who were screened positive for possible dementia on the international Residential Assessment’s Cognitive Performance Scale. People with possible alternative explanations for impaired cognitive performance such as depression and other neurological conditions were excluded from analysis. The 5202 eligible individuals were categorized into two groups: (1) those with a recorded diagnosis of dementia (64%) and (2) those without a recorded diagnosis of dementia (i.e. possible undetected dementia group) (36%). Logistic regression was used to evaluate the association between individual characteristics and possible undetected dementia. Significant risk factors for being in the possible undetected dementia group included Asian ethnicity, living alone, not having participated in long-standing social activities recently, major life stressors, and limited accessibility of their house. The knowledge gained from this study could enable targeting of services and resources for the groups at risk of undetected dementia to have a more equitable access to early diagnosis.

Clinically significant discrepancies between sleep problems assessed by standard clinical tools and actigraphy

Background

Sleep disturbances are widespread among nursing home (NH) patients and associated with numerous negative consequences. Identifying and treating them should therefore be of high clinical priority. No prior studies have investigated the degree to which sleep disturbances as detected by actigraphy and by the sleep-related items in the Cornell Scale for Depression in Dementia (CSDD) and the Neuropsychiatric Inventory – Nursing Home version (NPI-NH) provide comparable results. Such knowledge is highly needed, since both questionnaires are used in clinical settings and studies use the NPI-NH sleep item to measure sleep disturbances. For this reason, insight into their relative (dis)advantages is valuable.

Method

Cross-sectional study of 83 NH patients. Sleep was objectively measured with actigraphy for 7 days, and rated by NH staff with the sleep items in the CSDD and the NPI-NH, and results were compared. McNemar's tests were conducted to investigate whether there were significant differences between the pairs of relevant measures. Cohen's Kappa tests were used to investigate the degree of agreement between the pairs of relevant actigraphy, NPI-NH and CSDD measures. Sensitivity and specificity analyses were conducted for each of the pairs, and receiver operating characteristics (ROC) curves were designed as a plot of the true positive rate against the false positive rate for the diagnostic test.

Results

Proxy-raters reported sleep disturbances in 20.5% of patients assessed with NPI-NH and 18.1% (difficulty falling asleep), 43.4% (multiple awakenings) and 3.6% (early morning awakenings) of patients had sleep disturbances assessed with CSDD. Our results showed significant differences (p<0.001) between actigraphy measures and proxy-rated sleep by the NPI-NH and CSDD. Sensitivity and specificity analyses supported these results.

Conclusions

Compared to actigraphy, proxy-raters clearly underreported NH patients' sleep disturbances as assessed by sleep items in NPI-NH and CSDD. The results suggest that the usefulness of proxy-rater measures of sleep may be questionable and further research is needed into their clinical value. The results highlight the need for NH staff to acquire and act on knowledge about sleep and sleep challenges among NH patients.

Trial registration

Registered at www.clinicaltrials.gov (registration number NCT02238652) on July 7th 2014 (6 months after study initiation).

Associations between physical function and depression in nursing home residents with mild and moderate dementia: a cross-sectional study

OBJECTIVES

The primary aim of this study is to describe depression and physical function in nursing home residents with dementia, as well as to examine the associations between depression and balance function, lower limb muscle strength, mobility and activities of daily living. The secondary aim is to examine the differences in physical function between the groups classified as depressed and not depressed.

DESIGN

The study has a cross-sectional design.

SETTING

A convenience sample of 18 nursing homes in, and around, Oslo, Norway, participated.

PARTICIPANTS

We included 170 nursing home residents aged 60-100 years with mild or moderate degree of dementia defined by a score of 1 or 2 on the Clinical Dementia Rating Scale (CDR).

OUTCOME MEASURES

Assessments used were Cornell Scale for Depression in Dementia (CSDD), Berg Balance Scale (BBS), 'the 6-metre walking test' (walking speed), 30 s Chair Stand Test (CST) and the Barthel Index (BI).

RESULTS

Nursing home residents with dementia are a heterogeneous group in terms of physical function and depression. By applying the recommended cut-off of ≥8 on CSDD, 23.5% of the participants were classified as being depressed. The results revealed significant associations between higher scores on CSDD (indicating more symptoms of depression) and lower scores on BBS (95% CI -0.12 to -0.02, p=0.006), 30 s CST (95% CI -0.54 to -0.07, p=0.001) as well as maximum walking speed (95% CI -4.56 to -0.20, p=0.003) (indicating lower level of physical function).

CONCLUSION

Better muscle strength, balance and higher walking speed were significantly associated with less depressive symptoms. The potential interaction of dementia with poor physical function and depression indicates an area to explore in future epidemiological studies with a prospective design.

TRIAL REGISTRATION NUMBER

NCT02262104.

Simulated presence therapy for dementia

BACKGROUND

Dementia is a common and serious neuropsychiatric syndrome, characterised by progressive cognitive and functional decline. The majority of people with dementia develop behavioural disturbances, also known as behavioural and psychological symptoms of dementia (BPSD). Several non-pharmacological interventions have been evaluated to treat BPSD in people with dementia. Simulated presence therapy (SPT), an intervention that uses video or audiotape recordings of family members played to the person with dementia, is a possible approach to treat BPSD.

OBJECTIVES

To assess the effects of SPT on behavioural and psychological symptoms and quality of life in people with dementia.

SEARCH METHODS

We searched ALOIS (the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group), CENTRAL (The Cochrane Library) (9 February 2016), MEDLINE Ovid SP (1946 to 6 January 2017), Embase Ovid SP (1972 to 6 January 2017), PsycINFO Ovid SP (1806 to 6 January 2017), CINAHL via EBSCOhost (1980 to 6 January 2017), LILACS via BIREME (all dates to 6 January 2017), ClinicalTrials.gov (ClinicalTrials.gov) (all dates to 6 January 2017), and the World Health Organization (WHO) Portal (apps.who.int/trialsearch) (all dates to 6 January 2017). We also checked the reference lists of relevant articles to identify any additional studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials, including cross-over studies, that evaluated the efficacy of SPT, consisting of personalised audio or videotape recordings of family members, in people with any form of dementia.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed risk of bias and extracted data. No meta-analyses were conducted because of substantial heterogeneity among the included studies.

MAIN RESULTS

Three trials with 144 participants met the inclusion criteria. Two of the trials had a randomised cross-over design, one was a cross-over trial which we classified as quasi-randomised.Participants in the included studies were people with dementia living in nursing homes. They were predominantly women and had a mean age of over 80 years. SPT was performed using an audio or video recording prepared by family members or surrogates. It varied in its content, frequency of administration and duration. All the studies compared multiple treatments. In one study, SPT was compared with two other interventions; in the other two studies, it was compared with three other interventions. Specifically, SPT was compared to usual care, personalised music (two studies), a 'placebo' audiotape containing the voice of a person (two studies), and one-to-one social interaction performed by trained research assistants (one study). In terms of outcomes evaluated, one study considered agitation and withdrawn behaviour (both assessed with three methods); the second study evaluated verbal disruptive behaviour (assessed with three methods); and the third study evaluated physically agitated behaviour and verbally agitated behaviour (the method used was not clearly described).According to the GRADE criteria, the overall quality of the evidence was very low due to very small numbers of participants and risk of bias in the included studies; (none of the trials was at low risk of selection bias; all the trials were at high risk of performance bias; one trial was at high risk of attrition bias; and all had unclear selective reporting).Because of variation in the participants, the format of SPT, the comparison interventions, and the measures used to assess outcomes, we judged the results unsuitable for a meta-analysis.Within each trial, the effect of SPT on behaviour, compared to usual care, was mixed and depended on the measure used. Two trials which included a personalised music intervention reported no significant differences between simulated presence and music on behavioural outcomes. Because the overall quality of the evidence was very low, we were very uncertain regarding all the resultsNone of the studies evaluated quality of life or any of our secondary outcome measures (performance of activities of daily living, dropout and carer burden).

AUTHORS' CONCLUSIONS

We were unable to draw any conclusions about the efficacy of SPT for treating behavioural and psychological symptoms and improving quality of life of people with dementia. New high-quality studies are needed to investigate the effect of SPT.

Investigating the Prevalence of Dementia and Its Associated Risk Factors in a Chinese Nursing Home

BACKGROUND AND PURPOSE

The objective of this study was to determine the prevalence of and risk factors for dementia in residents aged 65 years and older in a Chinese nursing home.

METHODS

A cross-sectional study was carried out in a nursing home located in Hangzhou, Zhejiang Province, China. Cognitive status, including the presence of dementia and mild cognitive impairment (MCI), was measured using a combination of medical history and objective cognitive assessments. Logistic regression analysis was conducted to predict the associated risk factors.

RESULTS

In total, 943 residents (334 males and 609 females) aged 84.00±6.67 years (mean±SD) were included. Dementia was diagnosed in 420 (44.5%) residents, and MCI was diagnosed in 195 (20.7%). Mild, moderate, and severe dementia were present in 20.3%, 14.0%, and 65.7% of those in the dementia group, respectively. Logistic regression analysis revealed that dementia was associated with a low education level (p=0.000), an advanced age (p=0.010), and a history of stroke (p=0.023).

CONCLUSIONS

Our study found a high prevalence of dementia in a Chinese nursing home, and a high prevalence of patients with severe dementia. Risk factors for dementia included a low educational level, an advanced age, and a history of stroke. Appropriate interventions need to be applied to this population.

Prevalence of dementia, cognitive status and associated risk factors among elderly of Zhejiang province, China in 2014

BACKGROUND

the prevalence of dementia in China has risen dramatically in recent decades, but it is not well understood the status in the elderly population in Zhejiang province, eastern China.

METHODS

a cross-sectional survey was conducted in four communities across 12 counties in Zhejiang province from May to November 2014. Recruitment included 2,015 subjects aged 65 or older. Trained assessors performed assessments and interviews and collected information. Dementia was diagnosed according to the NIA-AA criteria in 2011.

RESULTS

the age-gender-standardised prevalence rates of dementia, Alzheimer's disease and vascular dementia were 13.0, 6.9 and 0.5%, respectively. There were significant increasing trends of rates over ages. Elderly, low educational level, heavy smoking, heavy alcohol consumption, diabetes and stroke were associated with dementia; tea consumption was associated with low prevalence of Alzheimer's disease and severe cognitive impairment.

CONCLUSIONS

dementia and cognitive impairment were relatively high among the elderly in Zhejiang province; more attention and population-based strategies are needed.

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.

Simulated presence therapy for dementia: a systematic review protocol

INTRODUCTION

The majority of patients with dementia develop behavioural and psychological symptoms of dementia (BPSD). Non-pharmacological interventions are an appealing alternative for the treatment of BPSD in patients with dementia. Simulated presence therapy (SPT) is a simple and inexpensive non-pharmacological intervention that can be used to treat BPSD. We propose a Cochrane protocol for the collection and assessment of evidence concerning the efficacy of SPT to treat relevant outcomes in people with dementia.

METHODS AND ANALYSIS

We will search the following electronic databases: the Cochrane Dementia and Cognitive Improvement Group's Specialised Register MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, CENTRAL and a number of trial registers as well as grey literature sources. We will include randomised and quasi-randomised controlled trials (including cross-over studies) that evaluated SPT in people with dementia. Comparators such as usual care with no additional activity, or any activity that differs in content and approach from SPT, but is additional to usual care, will be considered. The primary outcomes of interest will comprise behavioural and psychological symptoms, as measured by relevant scales, and quality of life. Two review authors working independently and in tandem will be involved in title and abstract screening, full-text screening and data abstraction. Where possible, quantitative data will be pooled, and relative risk and mean difference with 95% CI will be employed for dichotomous and continuous data, respectively. Assessment of risk of bias will be performed using the Cochrane risk-of-bias tool and the Grades of Recommendation, Assessment, Development and Evaluation approach.

ETHICS AND DISSEMINATION

Ethics approval is not required. The final results of this systematic review will be presented to the Cochrane Library and will also be disseminated at relevant conference presentations.

TRIAL REGISTRATION NUMBER

CRD42015029778.

[A comparison of the efficacy and safety of memantal and original memantine in the treatment of mild and moderate dementia in Alzheimer's disease]

OBJECTIVE

To estimate the efficacy and safety of original memantine and generic medication (memantal) in patients with mild/ moderate dementia due to Alzheimer's disease (AD).

MATERIAL AND METHODS

A six-month randomized controlled comparative study included 50 patients with mild/moderate dementia due to AD. Patients were naive to memantine and IAChe. Original memantine and generic medication dosage (5 mg daily) was titrated according to the manufacturer's recommendations. Patient's condition was assessed with MMSE, the Neuropsychiatric Inventory (NPI) and IADL. Side-effects were recorded.

RESULTS

There were no statistically significant differences in cognitive functions, neuropsychiatric symptoms, instrumental activity and safety between original memantine and generic medication. Both medications slightly improved patient's cognitive functioning, mostly in patients with mild dementia due to senile type of AD.

CONCLUSION

The generic medication (memantal) and original memantine have equal efficacy and safety in patients with mild/moderate dementia due to AD.

A Prospective Comparison of Informant-based and Performance-based Dementia Screening Tools to Predict In-Hospital Delirium

Dementia is an important risk factor for delirium, but the optimal strategy for incorporating cognitive impairment into delirium risk assessment at the time of hospital admission is unknown. We compared 2 informant-based screening tools for dementia and mild cognitive impairment [AD8 and D=(MC)] to the Mini Mental State Examination (MMSE) and Mini-cog in predicting hospital-acquired delirium. This prospective cohort study at an academic medical center consisted of 162 medical inpatients over age 50 years without delirium upon admission. Each participant was evaluated using the MMSE, Mini-cog, AD8, and D=(MC) upon admission and was assessed daily for delirium. An MMSE≤24 carried a 5.5 [95% confidence intervals (CI), 2.7-11.1] relative risk for delirium, whereas cognitive impairment detected by the Mini-cog, D=(MC), or AD8 carried a 2-fold risk. Adding the D=(MC) to the MMSE increased the sensitivity for predicting delirium from 52% (range, 32% to 73%) for the MMSE alone to 65% (range, 46% to 85%) if either test was positive. If both were positive, specificity was maximized at 97% (range, 94% to 100%), but sensitivity was 17% (range, 2% to 33%). The MMSE and Mini-cog identify a large proportion of patients at risk for hospital-acquired delirium, but the combination of performance-based and an informant-based screens may maximize specificity and sensitivity.

Persistence and adherence with dementia pharmacotherapy: relevance of patient, provider, and system factors

This paper provides a comprehensive review of studies examining adherence and (or) persistence with dementia pharmacotherapy during the past decade, including a summary of the key patient-, drug-, system-, and provider-level factors associated with these measures. Estimates of adherence and 1-year persistence to these drugs have ranged from 34% to 94% and 35% to 60%, respectively. Though many studies reported nonsignificant associations, there are data suggesting that patient age, sex, ethnoracial background, socioeconomic status, and region-specific reimbursement criteria, as well as the extent and quality of interactions among patients, caregivers, and providers, may influence persistence with pharmacotherapy. As many studies relied on administrative data, limited information was available regarding the relevance of patient's cognitive and functional status or the importance of caregiver involvement or assistive devices to adherence or persistence.

The UP-TECH project, an intervention to support caregivers of Alzheimer's disease patients in Italy: study protocol for a randomized controlled trial

BACKGROUND

The epidemic of Alzheimer's disease (AD) represents a significant challenge for the health care and social service systems of many developed countries. AD affects both patients and family caregivers, on whom the main burden of care falls, putting them at higher risk of stress, anxiety, mortality and lower quality of life. Evidence remains controversial concerning the effectiveness of providing support to caregivers of AD patients, through case management, counseling, training, technological devices and the integration of existing care services. The main objectives of the UP-TECH project are: 1) to reduce the care burden of family caregivers of AD patients; and 2) to maintain AD patients at home.

METHODS/DESIGN

A total of 450 dyads comprising AD patients and their caregivers in five health districts of the Marche region, Italy, will be randomized into three study arms. Participants in the first study arm will receive comprehensive care and support from a case manager (an ad hoc trained social worker) (UP group). Subjects in the second study arm will be similarly supported by a case manager, but in addition will receive a technological toolkit (UP-TECH group). Participants in the control arm will only receive brochures regarding available services. All subjects will be visited at home by a trained nurse who will assess them using a standardized questionnaire at enrollment (M0), 6 months (M6) and 12 months (M12). Follow-up telephone interviews are scheduled at 24 months (M24). The primary outcomes are: 1) caregiver burden, measured using the Caregiver Burden Inventory (CBI); and 2) the actual number of days spent at home during the study period, defined as the number of days free from institutionalizations, hospitalizations and stays in an observation unit of an emergency room.

DISCUSSION

The UP-TECH project protocol integrates previous evidence on the effectiveness of strategies in dementia care, that is, the use of case management, new technologies, nurse home visits and efforts toward the integration of existing services in an ambitious holistic design. The analysis of different interventions is expected to provide sound evidence of the effectiveness and cost of programs supporting AD patients in the community.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01700556.

Prevalence and potentially reversible factors associated with anorexia among older nursing home residents: results from the ULISSE project

OBJECTIVE

The principal aims of the present study were to explore the prevalence of anorexia and the factors correlated to anorexia in a large population of older people living in nursing home. Secondary, we evaluated the impact of anorexia on 1-year survival.

METHODS

Data are from baseline evaluation of 1904 participants enrolled in the Un Link Informatico sui Servizi Sanitari Esistenti per l'Anziano study, a project evaluating the quality of care for older persons living in an Italian nursing home. All participants underwent a standardized comprehensive evaluation using the Italian version of the inter Resident Assessment Instrument Minimum Data Set (version 2.0) for Nursing Home. We defined anorexia as the presence of lower food intake. The relationship between covariates and anorexia was estimated by deriving ORs and relative 95% CIs from multiple logistic regression models including anorexia as the dependent variable of interest. Hazard ratios and 95% CIs for mortality by anorexia were calculated.

RESULTS

More than 12% (240 participants) of the study sample suffered from anorexia, as defined by the presence of decreased food intake or the presence of poor appetite. Participants with functional impairment, dementia, behavior problems, chewing problems, renal failure, constipation, and depression, those treated with proton pump inhibitors and opioids had a nearly 2-fold increased risk of anorexia compared with participants not affected by these syndromes. Furthermore, participants with anorexia had a higher risk of death for all causes compared with nonanorexic participants (hazard ratio 2.26, 95% CI: 2.14-2.38).

CONCLUSIONS

The major finding is that potentially reversible causes, such as depression, pharmacologic therapies, and chewing problems, were strongly and independently associated with anorexia among frail older people living in nursing home. Furthermore, anorexia was associated with higher rate of mortality, independently of age and other clinical and functional variables.