Trajectories of cognitive decline in different types of dementia

The experiences of caring for someone with dementia and a learning disability: A qualitative systematic review

BACKGROUND

The life expectancy of people with a learning disability is increasing and with this comes a greater risk of developing dementia. Dementia poses new challenges for both family and formal learning disability carers as they try to support dementia's progressive nature and quality of life for their care recipient. This qualitative systematic review explores the evidence base of family and formal carers' experiences and needs of caring for someone with both a learning disability and dementia.

METHODS

Six electronic databases (PubMed, PsycINFO, Cochrane Library, Prospero, Scopus, CINAHL), were searched in May 2022, utilising a predefined search strategy. Thirteen papers fulfilled inclusion criteria and were included in in the review.

RESULTS

Thematic synthesis was used to explore and synthesise the qualitative findings of the studies. Four conceptual themes were identified following analysis: Knowledge and skills, Accessing support, Repercussions of dementia for carers, Influences of continuity of caring role.

CONCLUSION

There are significant training and educational needs for all carers who support the dual diagnosis of dementia and learning disability. Differences between family and formal carers relate to the organisational support and process available to formal carers. Parity across services combined with sufficiently trained carers may support dementia diagnosis and improve quality of care provided. Further research is needed to address environmental, and economic barriers carers face to facilitate ageing in place for their care recipients.

Effect of hormonal therapies for prostate cancer on cognition: The ongoing search for clarity

Hormonal therapy for advanced prostate cancer with androgen deprivation and novel androgen‐receptor axis–targeted therapy have produced mixed results on cognitive effects in previous studies. The most robust meta‐analysis to date shows a lack of objective cognitive changes across all domains at 6 months of treatment, although significant patient‐perceived, subjective decline suggests that concerns remain warranted, and further high‐quality, prospective studies are ultimately needed for greater certainty on longer term outcomes.

Effects of fruit and vegetable intake on memory and attention: a systematic review of randomized controlled trials

BACKGROUND

Memory and attention are important for daily functioning, and their function deteriorates due to aging. However, fruit and vegetable consumption are one of the protective factors against deterioration in memory and attention. This systematic review of randomized controlled trials (RCTs) aims to identify the effects of fruit and vegetable consumption on memory and attention.

METHODS

We conducted a systematic search in EBSCOhost, ProQuest, PubMed, Embase, and Web of Science from inception up to 06/09/2022. The inclusion criteria were peer-reviewed articles, fruit and vegetable intake measured using randomized controlled trials, and the outcome measures that showed the results of memory and attention scores. Two researchers independently extracted articles that met the selection criteria and evaluated the quality of each study.

RESULTS

There were 70 articles identified from the databases, of which 13 articles met the inclusion criteria and were included in this systematic review. There were 493 participants in total. The results show that consumption of fruit and vegetable intake improved memory and attention in longitudinal studies (10 to 12 weeks). Children showed improvement in immediate recall after supplementation with blueberries. Older adults required a higher dose of fruit and vegetable intake consumption to achieve significant improvement compared with children and younger adults. Furthermore, the effect of fruits and vegetables on memory showed better immediate memory recall than delayed recall.

CONCLUSION

This systematic review showed that there is an improvement in memory and attention with fruit and vegetable intake consumption. Hence, awareness of fruit and vegetable intake consumption is important to maintain cognitive health.

The pursuit for markers of disease progression in behavioral variant frontotemporal dementia: a scoping review to optimize outcome measures for clinical trials

Behavioral variant frontotemporal dementia (bvFTD) is a neurodegenerative disorder characterized by diverse and prominent changes in behavior and personality. One of the greatest challenges in bvFTD is to capture, measure and predict its disease progression, due to clinical, pathological and genetic heterogeneity. Availability of reliable outcome measures is pivotal for future clinical trials and disease monitoring. Detection of change should be objective, clinically meaningful and easily assessed, preferably associated with a biological process. The purpose of this scoping review is to examine the status of longitudinal studies in bvFTD, evaluate current assessment tools and propose potential progression markers. A systematic literature search (in PubMed and Embase.com) was performed. Literature on disease trajectories and longitudinal validity of frequently-used measures was organized in five domains: global functioning, behavior, (social) cognition, neuroimaging and fluid biomarkers. Evaluating current longitudinal data, we propose an adaptive battery, combining a set of sensitive clinical, neuroimaging and fluid markers, adjusted for genetic and sporadic variants, for adequate detection of disease progression in bvFTD.

Physical activity, sedentary behaviour, and cognitive function among older adults: A bibliometric analysis from 2004 to 2024

Because of population ageing, there will be a vast increase in the prevalence of cognitive decline and dementia. Physical activity and sedentary behaviour have been identified as modifiable lifestyle behaviours associated with these cognitive conditions. Therefore, the aim of this bibliometric analysis is to reveal the knowledge structure of the field of physical activity, sedentary behaviour, and cognitive function among older adults from 2004 to 2024, and to predict emerging research trends. A total of 1290 publications were retrieved from the Web of Science Core Collection. CiteSpace and VOSviewer were applied to conduct performance analysis, science mapping, and enrichment. T. Liu-Ambrose was the most prolific author (39 publications), and the University of British Columbia was the most prolific institution (48 publications). The USA, China, and Canada were the three most productive countries with 392, 174, and 136 publications respectively. Two research trends revealed the knowledge structure of this field, including the shift from evaluating the effectiveness of interventions on cognitive function to evaluating the effectiveness of interventions on other health-related outcomes, as well as an expansion of research on the role of physical activity and sedentary behaviour in the context of healthy ageing. Sleep, sedentary behaviour, and virtual reality may be emerging research trends and may predict directions for future research. Collectively, this bibliometric analysis provides a one-step overview of the knowledge structure in this field for researchers and other stakeholders, as well as a reference for future research.

The assessment of executive function abilities in healthy and neurodegenerative aging-A selective literature review

Numerous studies have examined executive function (EF) abilities in cognitively healthy older adults and those living with mild cognitive impairment (MCI) and Alzheimer's disease (AD). Currently, there are no standard accepted protocols for testing specific EFs; thus, researchers have used their preferred tool, which leads to variability in assessments of decline in a particular ability across studies. Therefore, there is a need for guidance as to the most sensitive tests for assessing EF decline. A search of the most current literature published between 2000 and 2022 on EF studies assessing cognitively healthy older adults and individuals living with MCI and AD was conducted using PubMed/Medline, PsycINFO, Embase, Web of Science, and Google Scholar. Emphasis was placed on the EF's dual-tasking, inhibition, shifting or switching, and working memory updating. Many tasks and their outcomes were reviewed. Of particular importance was the difference in outcomes for tasks applied to the same group of participants. These various EF assessment tools demonstrate differences in effectively identifying decline in EF ability due to the aging process and neurodegenerative conditions, such as MCI and AD. This review identifies various factors to consider in using particular EF tasks in particular populations, including task demand and stimuli factors, and also when comparing differing results across studies.

Irreversible postoperative cognitive impairment after unruptured intracranial aneurysm treatment in the elderly

PURPOSE

Postoperative cognitive dysfunction and recovery remain unclear in older patients undergoing interventional therapies for unruptured intracranial aneurysms (UIAs). This study aimed to compare changes in postoperative cognitive function between younger and older patients and to detect factors associated with non-recovery from postoperative cognitive dysfunction.

METHODS

This study reviewed 59 consecutive patients with UIAs who underwent interventional therapies, including microsurgical clipping or endovascular treatment, from 2021 to 2022. All patients were divided into the older (aged ≥ 70 years) and younger (aged < 70 years) groups. Mini-Mental State Examination (MMSE) and Frontal Assessment Battery (FAB) were performed within 2 months before interventions, at 1 week postoperatively (POW1), and 3-6 months postoperatively (POM3-6).

RESULTS

MMSE and FAB scores decreased more frequently in the older group than in the younger group at POW1 (older vs. younger: MMSE: 48% vs. 21%, p < 0.05; FAB: 56% vs. 18%, p < 0.01). In the older group, the FAB Z-score decreased in POW1 and recovered by POM3-6 (p < 0.01), while the MMSE Z-score continued to decrease (p = 0.04). Age and the preoperative MSME Z-score were significantly associated with non-recovery from decreased MMSE score at POM3-6 (recovery vs. non-recovery, age: 62 years old vs. 72 years old, p = 0.03, preoperative MMSE Z-score: 0.16 vs. - 0.90, p < 0.01).

CONCLUSIONS

This retrospective study found that older patients were more likely to have a postoperative cognitive decline after UIA treatment and implicated that global cognitive function tended to decline more than executive function in the long term. In addition, this study demonstrated that lower preoperative cognitive function was associated with inadequate postoperative cognitive recovery. The findings potentially contribute to the establishment of indications for treating UIAs in older patients.

The Relation Between Arterial Hypertension and Cognitive Impairment: A Literature Review

The global increase in dementia cases, driven by improved life expectancy and reduced elderly mortality rates, presents a significant public health challenge. Dementia, characterized by a gradual and irreversible decline in cognitive abilities, affects individuals aged 65 and older, disrupting lives and straining healthcare systems. Hypertension significantly influences dementia development. Research consistently links midlife hypertension to cognitive decline, mild cognitive impairment (MCI), and dementia, but findings in older adults vary. While some studies suggest that late-life hypertension accelerates cognitive decline and dementia risk, others propose a protective effect. The impact of hypertension on cognition varies across age groups, spanning from childhood to late life. High blood pressure during midlife and earlier life stages consistently predicts poorer cognitive outcomes. Executive function, attention, and motor speed are the cognitive domains most affected by hypertension, particularly in subcortical diseases. Memory impairments in hypertension-related dementias are complex, often overlapping with other causes. Understanding the inconsistent findings in older adults regarding hypertension, cognitive decline, and dementia risk requires comprehensive exploration of methodological and biological factors. Addressing hypertension and its management may hold the key to reducing the risk of cognitive decline and dementia, especially in midlife and earlier life stages.

Effectiveness, acceptability, and completeness and quality of intervention reporting of psychological interventions for people with dementia or mild cognitive impairment: protocol for a mixed-methods systematic review

INTRODUCTION

Mental health difficulties such as anxiety and depression have negative impacts on psychological well-being and are common in people with dementia and mild cognitive impairment. However, access to psychological treatments is limited. This mixed-method systematic review will: (1) examine the effectiveness of psychological interventions to improve mental health and psychological well-being in people with dementia or mild cognitive impairment; (2) examine the effectiveness of these psychological interventions to improve mental health and psychological well-being in informal caregivers; (3) examine potential clinical and methodological moderators associated with effectiveness; (4) explore factors associated with the acceptability of psychological interventions from the perspective of key stakeholders; and (5) examine the completeness and quality of intervention reporting.

METHODS AND ANALYSIS

Electronic databases (ASSIA, CENTRAL, CINAHL, EMBASE, PsycINFO and MEDLINE) will be systematically searched and supplemented with expert contact, reference and citation checking, and grey literature searches. If possible, we will conduct a meta-analysis to examine the overall effectiveness of psychological interventions to improve mental health and psychological well-being in people with dementia or mild cognitive impairment and their informal caregivers; and examine potential clinical and methodological moderators associated with effectiveness. We will conduct a deductive framework synthesis, informed by the theoretical framework of acceptability, to explore factors associated with the acceptability of psychological interventions from the perspective of key stakeholders. In accordance with Joanna Briggs Institute guidance, we will adopt a convergent segregated approach to data synthesis and integration of quantitative and qualitative findings. We will examine the completeness and quality of intervention reporting according to the Template for Intervention Description and Replication checklist and guide.

ETHICS AND DISSEMINATION

No primary data will be collected, and therefore, ethical approval is not required. Results will be disseminated through a peer-reviewed publication, academic conferences, and plain language summaries.

PROSPERO REGISTRATION NUMBER

CRD42023400514.

Neuropsychological differential diagnosis of Alzheimer's disease and vascular dementia: a systematic review with meta-regressions

Introduction

Diagnostic classification systems and guidelines posit distinguishing patterns of impairment in Alzheimer's (AD) and vascular dementia (VaD). In our study, we aim to identify which diagnostic instruments distinguish them.

Methods

We searched PubMed and PsychInfo for empirical studies published until December 2020, which investigated differences in cognitive, behavioral, psychiatric, and functional measures in patients older than 64 years and reported information on VaD subtype, age, education, dementia severity, and proportion of women. We systematically reviewed these studies and conducted Bayesian hierarchical meta-regressions to quantify the evidence for differences using the Bayes factor (BF). The risk of bias was assessed using the Newcastle-Ottawa-Scale and funnel plots.

Results

We identified 122 studies with 17,850 AD and 5,247 VaD patients. Methodological limitations of the included studies are low comparability of patient groups and an untransparent patient selection process. In the digit span backward task, AD patients were nine times more probable (BF = 9.38) to outperform VaD patients (β g = 0.33, 95% ETI = 0.12, 0.52). In the phonemic fluency task, AD patients outperformed subcortical VaD (sVaD) patients (β g = 0.51, 95% ETI = 0.22, 0.77, BF = 42.36). VaD patients, in contrast, outperformed AD patients in verbal (β g = -0.61, 95% ETI = -0.97, -0.26, BF = 22.71) and visual (β g = -0.85, 95% ETI = -1.29, -0.32, BF = 13.67) delayed recall. We found the greatest difference in verbal memory, showing that sVaD patients outperform AD patients (β g = -0.64, 95% ETI = -0.88, -0.36, BF = 72.97). Finally, AD patients performed worse than sVaD patients in recognition memory tasks (β g = -0.76, 95% ETI = -1.26, -0.26, BF = 11.50).

Conclusion

Our findings show inferior performance of AD in episodic memory and superior performance in working memory. We found little support for other differences proposed by diagnostic systems and diagnostic guidelines. The utility of cognitive, behavioral, psychiatric, and functional measures in differential diagnosis is limited and should be complemented by other information. Finally, we identify research areas and avenues, which could significantly improve the diagnostic value of cognitive measures.

AI-based assessments of speech and language impairments in dementia

Recent advancements in the artificial intelligence (AI) domain have revolutionized the early detection of cognitive impairments associated with dementia. This has motivated clinicians to use AI-powered dementia detection systems, particularly systems developed based on individuals' and patients' speech and language, for a quick and accurate identification of patients with dementia. This paper reviews articles about developing assessment tools using machine learning and deep learning algorithms trained by vocal and textual datasets.

Learning potential and visuospatial memory could predict amyloid-beta positron emission tomography positivity in amnestic mild cognitive impairment

We investigate the role of neuropsychological tests, including the learning potential, in predicting amyloid-beta positron emission tomography (Aβ-PET) status in amnestic mild cognitive impairment (aMCI). This cross-sectional study included 64 patients with aMCI (31 Aβ-PET (-) and 33 (+)) who visited a memory impairment clinic at Pusan National University Hospital between 2014 and 2019. Patients underwent Aβ-PET scans using 18F-florbetaben and the Seoul Neuropsychological Screening Battery. Learning potential was determined based on the difference in scores between the first and third trials of the Seoul Verbal Learning test (SVLT). Binary logistic regression was used to demonstrate the association between Aβ-PET status and cognitive tests. Predictive ability of cognitive tests for Aβ deposition was investigated using receiver operating characteristic curves analysis. From logistic regression models, the SVLT learning potential and Rey-Osterrieth Complex Figure Test (RCFT) delayed recall were found to predict Aβ-PET positivity. The areas under the curve (AUC) of the SVLT learning potential and RCFT delayed recall were significantly different from 0.5. Our findings of an association between Aβ deposition status and learning potential and visuospatial memory suggest that these cognitive tests could be used to screen patients with aMCI for Aβ deposition status.

Dentists' Approaches to Treatment Decision-Making for People with Dementia: A Qualitative Study

INTRODUCTION

Globally, the number of people living with dementia (PLwD) is projected to increase substantially. Dentists will encounter an increasing number of PLwD retaining natural teeth who need dental care. Dental treatment planning can be complex for PLwD as both oral diseases and dental treatment can be detrimental to patients' oral and social function and comfort. In addition, patients may lack the capacity to make decisions about their treatment, posing further challenges for dentists.

OBJECTIVE

This study aimed to explore dentists' approach to treatment decision-making with or for PLwD.

METHODS

Semistructured one-to-one interviews were completed with 22 dentists between April 2020 and March 2021. Data generation and analysis followed the principles of constructivist grounded theory with data being collected and analyzed simultaneously using a maximum variation sample. Interviews were recorded, transcribed verbatim, and then analyzed, leading to a theoretical understanding of how dentists approach treatment decisions for PLwD.

RESULTS

Four data categories describe dentists' approaches to treatment decision-making for PLwD. Dentists sought to provide individualized care for PLwD. However, they described planning care based on risk-benefit analyses that primarily considered biomedical factors and generic assumptions. There was an underemphasis on the psychological or social implications of dental care or its delivery. Furthermore, while some dentists attempted to involve patients in treatment decisions, they reported fewer attempts to identify the views and preferences of PLwD identified as lacking decisional capacity. In this scenario, dentists reported leading the decision-making process with little regard for patients' known or identified preferences and minimal involvement of PLwD's family.

CONCLUSIONS

Dentists acknowledge the complexity in treatment decision-making for PLwD yet focused heavily on biomedical considerations, with an underemphasis on individuals' preferences and autonomy. Considering psychosocial aspects of care alongside biomedical factors is essential to support holistic person-centered care for this growing patient cohort.

KNOWLEDGE TRANSFER STATEMENT

This study highlighted that dentists may only be considering biomedical aspects of care when considering what treatment is appropriate for people living with dementia. When making or supporting treatment decisions, dentists should explore patients' preferences and actively consider relevant psychosocial factors. These can be actively identified through considered discussions with patients as well as their family members. Gathering this information should support more person-centered and value-concordant decision-making for people living with dementia.

Social and spatial inequalities in healthcare use among people living with dementia in England (2002-2016)

OBJECTIVES

Healthcare services for people living with dementia (PLWD) are stretched, and government promises of increased funding remain undelivered. With the UK dementia population to surpass 1 million by 2024, and dementia care costs predicted to almost treble by 2040, it is essential we understand differences in healthcare use among PLWD. This study aimed to explore social and spatial variations in healthcare use among people diagnosed with dementia (2002-2016).

METHODS

Data were derived from Electronic Health Records of Clinical Practice Research Datalink GP patients in England (n = 142,302). To standardise healthcare contacts, rates of healthcare contacts per year were calculated for three primary (GP observations and medications) and three secondary healthcare types [Accident & Emergency (A&E) attendances and, emergency and elective hospital admissions]. Fully-adjusted generalised linear regression models were used to identify healthcare use variation by social and spatial groups. Twelve models were generated, one for each healthcare type in early- and late-onset populations separately.

RESULTS

This study highlights numerous social and spatial variations in healthcare use among PLWD. Among PLWD, several groups tended to have healthcare service use more closely associated with negative outcomes, including a greater likelihood of A&E attendances and emergency and elective hospital admissions. These groups include: men, people from White ethnicity groups and people from more deprived and rural areas.

CONCLUSIONS

Systemic and social measures are needed to reduce variations in healthcare use inequalities in PWLD. These include greater healthcare continuity, health checks and medicines reviews, culturally appropriate services, better and more accessible treatment and improved infrastructure.

Soluble and insoluble protein aggregates, endoplasmic reticulum stress, and vascular dysfunction in Alzheimer's disease and cardiovascular diseases

Dementia refers to a particular group of symptoms characterized by difficulties with memory, language, problem-solving, and other thinking skills that affect a person's ability to perform everyday activities. Alzheimer's disease (AD) is the most common form of dementia, affecting about 6.2 million Americans aged 65 years and older. Likewise, cardiovascular diseases (CVDs) are a major cause of disability and premature death, impacting 126.9 million adults in the USA, a number that increases with age. Consequently, CVDs and cardiovascular risk factors are associated with an increased risk of AD and cognitive impairment. They share important age-related cardiometabolic and lifestyle risk factors, that make them among the leading causes of death. Additionally, there are several premises and hypotheses about the mechanisms underlying the association between AD and CVD. Although AD and CVD may be considered deleterious to health, the study of their combination constitutes a clinical challenge, and investigations to understand the mechanistic pathways for the cause-effect and/or shared pathology between these two disease constellations remains an active area of research. AD pathology is propagated by the amyloid β (Aβ) peptides. These peptides give rise to small, toxic, and soluble Aβ oligomers (SPOs) that are nonfibrillar, and it is their levels that show a robust correlation with the extent of cognitive impairment. This review will elucidate the interplay between the effects of accumulating SPOs in AD and CVDs, the resulting ER stress response, and their role in vascular dysfunction. We will also address the potential underlying mechanisms, including the possibility that SPOs are among the causes of vascular injury in CVD associated with cognitive decline. By revealing common mechanistic underpinnings of AD and CVD, we hope that novel experimental therapeutics can be designed to reduce the burden of these devastating diseases. Graphical abstract Alzheimer's disease (AD) pathology leads to the release of Aβ peptides, and their accumulation in the peripheral organs has varying effects on various components of the cardiovascular system including endoplasmic reticulum (ER) stress and vascular damage. Image created with BioRender.com.

Discovery of novel CSF biomarkers to predict progression in dementia using machine learning

Providing an accurate prognosis for individual dementia patients remains a challenge since they greatly differ in rates of cognitive decline. In this study, we used machine learning techniques with the aim to identify cerebrospinal fluid (CSF) biomarkers that predict the rate of cognitive decline within dementia patients. First, longitudinal mini-mental state examination scores (MMSE) of 210 dementia patients were used to create fast and slow progression groups. Second, we trained random forest classifiers on CSF proteomic profiles and obtained a well-performing prediction model for the progression group (ROC-AUC = 0.82). As a third step, Shapley values and Gini feature importance measures were used to interpret the model performance and identify top biomarker candidates for predicting the rate of cognitive decline. Finally, we explored the potential for each of the 20 top candidates in internal sensitivity analyses. TNFRSF4 and TGF [Formula: see text]-1 emerged as the top markers, being lower in fast-progressing patients compared to slow-progressing patients. Proteins of which a low concentration was associated with fast progression were enriched for cell signalling and immune response pathways. None of our top markers stood out as strong individual predictors of subsequent cognitive decline. This could be explained by small effect sizes per protein and biological heterogeneity among dementia patients. Taken together, this study presents a novel progression biomarker identification framework and protein leads for personalised prediction of cognitive decline in dementia.

Distinct disease trajectories in frontotemporal dementia-motor neuron disease and behavioural variant frontotemporal dementia: A longitudinal study

BACKGROUND AND PURPOSE

The heterogeneity of cognitive and behavioural disturbances in frontotemporal dementia-motor neuron disease (FTD-MND), and clinical differences between FTD-MND and FTD subtypes, have been illustrated cross-sectionally. This study aimed to examine the FTD-MND disease trajectory by comparing clinical features of FTD-MND and the behavioural variant FTD (bvFTD) longitudinally.

METHODS

Neuropsychological and disease severity assessments were conducted in a cohort of FTD-MND (baseline, n = 42; follow-up, n = 18) and bvFTD (baseline, n = 116; follow-up, n = 111) using a longitudinal, case-control design. Age-, sex-, and education-matched controls (n = 52) were recruited. Predictors of clinical progression were analyzed. Voxel-based morphometry analysis was undertaken to investigate the progression of brain atrophy.

RESULTS

At baseline, FTD-MND was characterized by semantic and general cognition deficits, whereas bvFTD had greater behavioural disturbances. General cognition and language deteriorated in FTD-MND when followed longitudinally. Language deficits at baseline predicted cognitive deterioration and disease progression and correlated with progressive atrophy of language regions. Further deterioration in behaviour was evident in bvFTD over time. The rate of disease progression (i.e., general cognition, semantic association, and disease severity) was significantly faster in FTD-MND than in bvFTD.

CONCLUSIONS

FTD-MND and bvFTD appear to have distinct disease trajectories, with more rapid progression in FTD-MND. Language impairments should be closely monitored in FTD-MND as potential predictors of cognitive deterioration and disease progression.

Cognitive Component Structure of a Neuropsychological Battery Administered to Cognitively-Normal Adults in the SIU Longitudinal Cognitive Aging Study

We used principal component analysis (PCA) to examine the component structure of a neuropsychological test battery administered to 943 cognitively-normal adults enrolled in the Southern Illinois University (SIU) Longitudinal Cognitive Aging Study (LCAS). Four components explaining the most variance (63.9%) in the dataset were identified: speed/cognitive flexibility, visuospatial skills, word-list learning/memory, and story memory. Regression analyses confirmed that increased age was associated with decreased component scores after controlling for gender and education. Our identified components differ slightly from previous studies using PCA on similar test batteries. Factors such as the demographic characteristics of the study sample, the inclusion of mixed patient and control samples, the inclusion of different test measures in previous studies, and the fact that many neuropsychological test measures assess multiple cognitive processes simultaneously, may help to explain these inconsistencies.

A Biopsychosocial Model of Mealtime Management in Persons with Dementia, an Asset-Based Approach to Patient-Centered Care

Considering the rapid increase in the population over the age of 65, there is increasing need to consider models of care for persons with dementia (PWD). One common deficit associated with dementia progression is difficulty with successful participation in mealtimes. Difficulty participating in mealtimes in PWD is not the result of one factor, but rather a confluence of biological, psychological, and social characteristics common in dementia. Factors leading to mealtime difficulties for PWD may include changes in cognitive status, altered sensorimotor functioning, and increased reliance on caregiver support. The complex nature of biological, psychological, and social factors leading to mealtime difficulty highlights the need for a pragmatic model that caregivers can utilize to successfully support PWD during mealtimes. Existing models of dementia and mealtime management were reviewed and collated to create a model of mealtime management that considers this complex interplay. The Biopsychosocial Model of Mealtime Management builds on past research around patient-centered care and introduces an asset-based approach to capitalize on a PWD's retained capabilities as opposed to compensating for disabilities associated with dementia. We hope this model will provide a framework for caregivers to understand what factors impact mealtime participation in PWD and provide appropriate means on intervention.

Cognitive Trajectories in Community-Dwelling Older Adults and Incident Dementia, Disability and Death: A 10-Year Longitudinal Study

Objective

The inter-individual variability in cognitive changes may be early indicators of major health events. We aimed to determine whether late-life cognitive trajectories were associated with incident dementia, persistent physical disability and all-cause mortality.

Methods

Data came from a cohort of older community-dwelling individuals aged 70 years or above in Australia and the United States. Global cognition, verbal fluency, episodic memory and psychomotor speed were assessed regularly at up to seven waves between 2010 and 2017. Dementia, disability in activities of daily living, and death were adjudicated between 2017 and 2020. Latent classes of cognitive trajectories over seven years were determined using group-based trajectory modeling. Multivariable logistic regression was used for the prospective associations between cognitive trajectories and these outcomes.

Results

Cognitive trajectories were defined for 16,174 participants (mean age: 78.9 years; 56.7% female) who were alive and without incident dementia or disability by 2017, among which 14,655 participants were included in the association analysis. Between three and five trajectory classes were identified depending on the cognitive test. Cognitive trajectories were strongly associated with the risk of dementia. For example, compared to those in the highest-functioning trajectory, the worst performers of episodic memory had a 37-fold increased risk of dementia (95% CI: 17.23–82.64). The lowest trajectories of both global cognition and episodic memory also predicted increased mortality risk (OR: 1.80, 95% CI: 1.28–2.52; OR: 1.61, 95% CI: 1.09–2.36, respectively), while only slow psychomotor speed was marginally associated with physical disability (OR: 2.39, 95% CI: 0.99–5.77).

Conclusions

In older individuals, cognitive trajectories appear to be early indicators of clinically relevant health outcomes. Systematic cognitive assessments as part of routine geriatric evaluation may facilitate early identification and interventions for those individuals at highest risk.

Evaluation of an education intervention for Australian health practitioners to support people with dementia with driving decisions: A pretest-posttest survey

OBJECTIVE

Drivers with dementia will at some stage need to stop driving. The timing of driving retirement is informed by the advice of health practitioners, however many find this task complex and challenging as they feel unprepared or lack confidence, having limited training and education on dementia and driving. Few opportunities exist for Australian health practitioners to advance learning about dementia and driving. This study evaluated the impact of a Dementia and Driving Education Module on practitioner self-perceived knowledge, confidence, and competence in supporting people living with dementia with decisions about driving.

METHODS

A single group, pretest-posttest survey was conducted for this study. Health practitioners were recruited over 19 months via email and invited to attend a face-to-face dementia and driving workshop. The workshop comprised of a two-hour Dementia and Driving Education Module including seven learning activities incorporating six vignettes, five self-reflections, one case study and a paper copy of a dementia and driving decision aid. Participants completed a survey prior to, immediately after and six weeks post completion of the education module.

RESULTS

A total of 240 health practitioners, from over six disciplines, took part in one of eleven workshops delivered via face-to-face and online across five states of Australia. Significant increases occurred in all outcome measures of perceived knowledge, confidence and competence between baseline and immediately post-education module survey responses and between baseline and six weeks post-survey responses.

CONCLUSIONS

The Dementia and Driving Education Module and accompanying decision aid demonstrate an efficacious solution for a diverse range of health practitioners to enhance their knowledge, confidence, and competence in supporting people living with dementia with driving retirement decisions.

Usefulness of 2D Video Analysis for Evaluation of Shoulder Range of Motion during Upper Limb Exercise in Patients with Psychiatric Disorders

Aging and its associated problems related to movement impacts the care of people with psychiatric disorders. This study sought to clarify the usefulness of 2D video analysis for evaluating shoulder range of motion (ROM) during upper limb exercises in patients with psychiatric disorders. Subjects (N=54) were patients with psychiatric disorders categorized as the following:having either a high or low activities of daily living (ADL) score using the Barthel Index;experiencing shoulder ROM limitation, and whether or not compensatory movements were exhibited. Compensatory movement was also considered in patients with Parkinsonism, cerebrovascular disease, and cognitive dysfunction. Shoulder joint ROM was measured using a goniometer and active ROM was captured using ImageJ. No significant difference between passive ROM measured by a goniometer and active ROM measured by ImageJ considering disease groups, ADL level, and shoulder ROM limitation was found. Factoring in compensatory movements, however, significant differences were found between passive and active ROM:existence compensatory movement group, left side (z=-2.30, p=0.02);nonexistence compensatory movement group, right side (z=-2.63, p<0.001). Image-evaluating devices help assess ROM in patients with psychiatric disorders, enhancing the development of physical rehabilitation programs to regain critical ADL, sustaining self-care capabilities. J. Med. Invest. 69 : 70-79, February, 2022.

Peer support for the newly diagnosed: how people with dementia can co-produce meeting centre services

This paper aims to contribute to the knowledge about open, co-produced meeting centres for people with dementia, from their own perspective. Services that support people who are newly diagnosed with dementia are often insufficient. Co-produced services have the potential to address the need of people with dementia to be useful and productive, while reducing the stigma. In this study, we applied a qualitative design. Data were collected at a meeting centre for people with newly diagnosed dementia, and consisted of fieldwork (13 days for about two hours at a time), written materials, and semi-structured interviews (mean length 30 minutes) with five attendees with dementia and two staff persons. The analysis was inspired by situational analysis. The findings showed that the meeting centre provided a place for human encounters, a break from everyday life, and a place to share knowledge and develop new skills. Further, challenges were described. Co-production consisted of the attendees being encouraged to take part in the planning of activities, learning from each other and providing mutual support. The study adds to previous knowledge about co-produced services for people with dementia. Future studies can clarify how co-production can be developed in services for people with newly diagnosed dementia in countries and regions where there is a dearth of this kind of support.

The role of disability and depressive symptoms in the relation between objective cognitive performance and subjective cognitive decline

BACKGROUND

Subjective cognitive decline (SCD) and subjective memory decline (SMD) are common among older people. Evidence linking SCD and SMD with cognitive and memory impairment is inconsistent. Moreover, little is known about the associations of SCD and SMD with disability. We aimed to explore the associations of SCD and SMD with objective cognitive and memory performance, disability, and depressive symptoms.

MATERIALS AND METHODS

In a cross-sectional study we conducted face to face interviews in a randomized sample of people aged ≥65 years living in the Canton of Ticino, southern Switzerland, between May 2021 and April 2022. We measured subjective cognitive decline with the MyCog, a subsection of the Subjective Cognitive Decline Questionnaire (SCD-Q); cognitive functioning with the Community Screening Instrument for Dementia; memory with the consortium to establish a registry for alzheimer's disease (CERAD) 10-word list learning task; and disability and depressive symptoms with the world health organization disability assessment schedule 2.0 (WHO-DAS 2.0) and the Euro-Depression (EURO-D) scales, respectively.

RESULTS

Of the 250 participants 93.6% reported at least one cognitive difficulty, and 40.0% SMD. Both SCD and SMD were associated with poorer objective cognitive/memory performance, and independently with greater disability, and more depressive symptoms. But in participants with high disability and depressive symptoms subjective and objective cognition were no longer associated. Disability fully mediated the associations of poorer objective cognitive and memory performance with subjective cognitive and memory decline.

CONCLUSION

Routine clinical assessments of cognitive function should include formal enquires about SCD and SMD, and also account for disability and depressive symptoms.

Characterizing the long-term cognitive impairment following delirium episodes: A call to action

The possible link between delirium and a long-term cognitive impairment is significant for patients, carers, and clinicians. To make progress, we need urgently novel advances in understanding the neural substrates underlying this cognitive impairment and any accompanying behavioral symptoms.

Speech and language impairments in behavioral variant frontotemporal dementia: A systematic review

Although behavioral variant frontotemporal dementia (bvFTD) is classically defined by behavioral and socio-emotional changes, impairments often extend to other cognitive functions. These include early speech and language deficits related to the disease's core neural disruptions. Yet, their scope and clinical relevance remains poorly understood. This systematic review characterizes such disturbances in bvFTD, considering clinically, neuroanatomically, genetically, and neuropathologically defined subgroups. We included 181 experimental studies, with at least 5 bvFTD patients diagnosed using accepted criteria, comparing speech and language outcomes between bvFTD patients and healthy controls or between bvFTD subgroups. Results reveal extensive and heterogeneous deficits across cohorts, with (a) consistent lexico-semantic, reading & writing, and prosodic impairments; (b) inconsistent deficits in motor speech and grammar; and (c) relative preservation of phonological skills. Also, preliminary findings suggest that the severity of speech and language deficits might be associated with global cognitive impairment, predominantly temporal or fronto-temporal atrophy and MAPT mutations (vs C9orf72). Although under-recognized, these impairments contribute to patient characterization and phenotyping, while potentially informing diagnosis and management.

Systems Biology and Chemoinformatics-Based Strategies to Explore the Biological Mechanism of Fugui Wenyang Decoction in Treating Vascular Dementia Rats

OBJECTIVE

To explore the biological mechanism of Fugui Wenyang Decoction (FGWYD) in treating vascular dementia (VD) rats based on systems pharmacology, proteomics, and a multidirectional pharmacology integration strategy.

METHODS

Chemoinformatics was utilized to construct and analyze the FGWYD-VD protein-protein interaction (PPI) network. Then, the total protein in the brain tissue of the infarcted side of the rat was extracted for protein identification, pattern identification, and protein quantitative analysis. The differentially expressed proteins are analyzed by bioinformatics. Finally, the important proteins in the oxidative stress-related biological process proteins and indicators were detected through experimental pharmacology to verify the findings of systems biology and chemoinformatics.

RESULTS

There were a total of 73 FGWYD components with 245 FGWYD and 145 VD genes. The results of GO enrichment analysis and pathway enrichment analysis showed that MBHD may regulate the inflammation module, oxidative stress, the synaptic plasticity regulation module, and the neuronal apoptosis section module. Compared with the sham operation group, there were 23 upregulated proteins and 17 downregulated proteins in the model group (P < 0.05). Compared with the model group, there were 16 upregulated proteins and 10 downregulated proteins in the FGWYD group (P < 0.05). Bioinformatics analysis shows that those proteins were closely related to processes such as inflammation, oxidative stress, neuronal apoptosis, neuronal growth and differentiation, signaling pathways, and transcriptional regulation. Multidirectional pharmacology further verified the neuroprotective mechanism of the Nrf2/HO-1 pathway in FGWYD treatment of VD.

CONCLUSION

The mechanism of FGWYD in the treatment of VD may be related to inflammation, oxidative stress, angiogenesis, and neuronal apoptosis.

A Systematic Review and Comparison of Neurocognitive Features of Late-Life Attention-Deficit/Hyperactivity Disorder and Dementia With Lewy Bodies

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) in adulthood and dementia with Lewy bodies (DLB) share many cognitive and noncognitive similarities. The overlapping features between both disorders complicate differential diagnosis. The aim of the current systematic review was to compare patterns of neuropsychological profiles in older adults with ADHD and DLB.

METHOD

Of the 1989 ADHD-related articles and 1332 DLB-related articles screened, 3 ADHD and 25 DLB articles were retained for qualitative synthesis and review.

RESULTS

A synthesis of individual study findings revealed isolated working memory deficits for late-life ADHD, and performance deficits in areas of attention, memory, language, and visuoperceptual abilities for DLB. Results were limited by small samples and absence of data in some cognitive domains.

CONCLUSION

These initial findings support potentially unique neurocognitive profiles for ADHD in later life and DLB that would enable practitioners to differentially diagnose and appropriately treat older adults presenting with these phenotypically similar disorders.

Associations of subjective cognitive and memory decline with depression, anxiety, and two-year change in objectively-assessed global cognition and memory

Research studies exploring the association of cognitive complaints with objectively assessed cognitive decline report inconsistent results. However, many of these have methodological limitations. We investigated whether 1) more severe subjective cognitive decline (SCD) and subjective memory decline (SMD) predict change in objectively assessed global cognition, remote memory, recent memory, learning; 2) the predictive value of more severe SMD over change in objectively assessed remote memory, recent memory, and learning is stronger for individuals that report an SMD that started within the past five years than for those that report an SMD that started five or more years previously and/or stronger for those that experienced SMD within the past two years than for those who had not; and 3) greater depression and anxiety are associated with more severe SCD and SMD. We used two-year longitudinal data from the CFAS-Wales study (N = 1,531; mean (SD) age = 73.0 (6.0) years). We fitted linear regression models. More severe SCD and SMD did not predict change in objectively assessed global cognition, remote memory, and recent memory but predicted lower scores in learning. The prediction of SMD over change in learning was not stronger when individuals reported an SMD that started within the past five years compared to when they reported an SMD that started five or more years previously nor when individuals reported an SMD that started within the past two years than those who did not. Greater depression and anxiety were associated with more severe SCD and SMD. More severe SMD may be useful for predicting lower learning ability and for identifying individuals experiencing depression and anxiety.

Cerebral small vessel disease and vascular cognitive impairment: from diagnosis to management

PURPOSE OF REVIEW

We present recent developments in the field of small vessel disease (SVD)-related vascular cognitive impairment, including pathological mechanisms, updated diagnostic criteria, cognitive profile, neuroimaging markers and risk factors. We further address available management and therapeutic strategies.

RECENT FINDINGS

Vascular and neurodegenerative pathologies often co-occur and share similar risk factors. The updated consensus criteria aim to standardize vascular cognitive impairment (VCI) diagnosis, relying strongly on cognitive profile and MRI findings. Aggressive blood pressure control and multidomain lifestyle interventions are associated with decreased risk of cognitive impairment, but disease-modifying treatments are still lacking. Recent research has led to a better understanding of mechanisms leading to SVD-related cognitive decline, such as blood-brain barrier dysfunction, reduced cerebrovascular reactivity and impaired perivascular clearance.

SUMMARY

SVD is the leading cause of VCI and is associated with substantial morbidity. Tackling cardiovascular risk factors is currently the most effective approach to prevent cognitive decline in the elderly. Advanced imaging techniques provide tools for early diagnosis and may play an important role as surrogate markers for cognitive endpoints in clinical trials. Designing and testing disease-modifying interventions for VCI remains a key priority in healthcare.

Factors associated with slow progression of cognitive impairment following first dementia diagnosis

OBJECTIVES

To investigate the extent to which slow progression of dementia after diagnosis might be predicted from routine longitudinal healthcare data, in order to clarify characteristics of people who experience this outcome.

METHODS

A retrospective observational study was conducted using data from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre Case Register. This study included all patients receiving a first dementia diagnosis between 2006 and 2017, restricted to those with a baseline Mini-Mental State Examination (MMSE) score within 6 months of initial diagnosis of dementia and at least one MMSE score after 3 years post-diagnosis. Slow progression was defined as a change in MMSE score of -1, 0 or an increase at the follow-up point. This group was compared to the remainder with an MMSE decline of -2 or more.

RESULTS

Overall, 682 patients with slow progression were compared to 1045 with faster progression. In the confounder-adjusted multivariate logistic regression model, slow progression was more likely in younger patients (age 65-74 years; odds ratio: 1.18; 95% confidence intervals: 1.04-1.37), males (1.24; 1.01-1.53), those with moderate or severe dementia according to MMSE, patients with mixed-type dementia (2.06; 1.11-3.82) compared to Alzheimer's disease and less likely in those receiving acetylcholinesterase inhibitor (AChEI) treatment (0.57; 0.46-0.71).

CONCLUSION

Slow dementia progression after diagnosis was common in patients with mixed Alzheimer's and vascular dementia, younger age, males and non-receipt of AChEIs, possibly suggesting non-Alzheimer pathologies and clarifying such predictors is important, as there is currently very limited information on which to base prognosis estimates in post-diagnosis counselling.

Association of Cognitive Function Trajectories in Centenarians With Postmortem Neuropathology, Physical Health, and Other Risk Factors for Cognitive Decline

IMPORTANCE

Understanding mechanisms associated with prolonged cognitive health in combination with exceptional longevity might lead to approaches to enable successful aging.

OBJECTIVE

To investigate trajectories of cognitive functioning in centenarians across domains, and to examine the association of these trajectories with factors underlying cognitive reserve, physical health, and postmortem levels of Alzheimer disease (AD)-associated neuropathology.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used neuropsychological test data and postmortem neuropathological reports from Dutch centenarians who were drawn from the 100-plus Study between January 2013 and April 2019. Eligible participants self-reported being cognitively healthy, which was confirmed by a proxy. Data analysis was performed between June 2019 and June 2020.

EXPOSURES

Age, sex, APOE ε genotype, factors of cognitive reserve, physical health, and AD-associated neuropathology (ie, amyloid-β, neurofibrillary tangles, and neuritic plaques).

MAIN OUTCOMES AND MEASURES

In annual visits (until death or until participation was no longer possible), centenarians underwent an extensive neuropsychological test battery, from which an mean z score of global cognition, memory, executive functions, verbal fluency, visuospatial functions, and attention/processing speed was calculated. Linear mixed models with a random intercept and time as independent variable were used to investigate cognitive trajectories, adjusted for sex, age, education, and vision and hearing capacities. In a second step, linear mixed models were used to associate cognitive trajectories with factors underlying cognitive reserve, physical health at baseline, and AD-associated neuropathology.

RESULTS

Of the 1023 centenarians approached, 340 were included in the study. We analyzed 330 centenarians for whom cognitive tests were available at baseline (239 [72.4%] women; median [interquartile range] age of 100.5 [100.2-101.7] years), with a mean (SD) follow-up duration of 1.6 (0.8) years. We observed no decline across investigated cognitive domains, with the exception of a slight decline in memory function (β, -0.10 SD per year; 95% CI, -0.14 to -0.05 SD; P < .001). Cognitive performance was associated with factors of physical health (eg, higher Barthel index: β, 0.37 SD per year; 95% CI, 0.24-0.49; P < .001) and cognitive reserve (eg, higher education: β, 0.41 SD per year; 95% CI, 0.29-0.53; P < .001), but none of these factors were associated with the rate of decline. Neuropathological reports were available for 44 participants. While centenarian brains revealed varying loads of postmortem neuropathological hallmarks of AD, this was not associated with cognitive performance or rate of decline.

CONCLUSIONS AND RELEVANCE

While we observed a slight vulnerability for decline in memory function, centenarians maintained high levels of performance in all other investigated cognitive domains for up to 4 years despite the presence of risk factors of cognitive decline. These findings suggest that mechanisms of resilience may underlie the prolongation of cognitive health until exceptional ages.

Autonomic function in amnestic and non-amnestic mild cognitive impairment: spectral heart rate variability analysis provides evidence for a brain-heart axis

Mild cognitive impairment (MCI) is a heterogeneous syndrome with two main clinical subtypes, amnestic (aMCI) and non-amnestic (naMCI). The analysis of heart rate variability (HRV) is a tool to assess autonomic function. Cognitive and autonomic processes are linked via the central autonomic network. Autonomic dysfunction entails several adverse outcomes. However, very few studies have investigated autonomic function in MCI and none have considered MCI subtypes or the relationship of HRV indices with different cognitive domains and structural brain damage. We assessed autonomic function during an active orthostatic challenge in 253 oupatients aged ≥ 65, [n = 82 aMCI, n = 93 naMCI, n = 78 cognitively normal (CN), neuropsychologically tested] with power spectral analysis of HRV. We used visual rating scales to grade cerebrovascular burden and hippocampal/insular atrophy (HA/IA) on neuroimaging. Only aMCI showed a blunted response to orthostasis. Postural changes in normalised low frequency (LF) power and in the LF to high frequency ratio correlated with a memory test (positively) and HA/IA (negatively) in aMCI, and with attention/executive function tests (negatively) and cerebrovascular burden (positively) in naMCI. These results substantiate the view that the ANS is differentially impaired in aMCI and naMCI, consistently with the neuroanatomic substrate of Alzheimer's and small-vessel subcortical ischaemic disease.

The Impact of Dementia on Oral Health and Dental Care, Part 2: Approaching and Planning Treatment

Dementia has been described as the biggest health and social care challenge of this century; its impact on dental care cannot be ignored. Dementia affects cognitive ability and decision making, so it is important that oral healthcare professionals are conversant with current mental capacity legislation and issues that may be raised when treatment planning for patients living with the condition. This second article in the series considers the impact of dementia on dental care provision and covers a range of issues which are relevant to both general and specialist practice. These include assessment of capacity, use of different treatment modalities, such as sedation and general anaesthesia, and the factors that may be relevant when deciding to offer treatment or to refer to a secondary care setting for dental treatment. Advanced care planning is detailed to support general dental practitioners considering the longer-term wishes of their patients with an early diagnosis of dementia.

Drum Communication Program Intervention in Older Adults With Cognitive Impairment and Dementia at Nursing Home: Preliminary Evidence From Pilot Randomized Controlled Trial

Introduction: Inactivity and consequent deterioration of cognitive and physical function is a major concern among older adults with the limited walking ability and need a high level of care in nursing homes. We aimed to test whether a drumming communication program (DCP) that uses the rhythmic response function of the elderly with cognitive impairment, dementia, and other debilitating disorders would improve their cognitive and physical function. Methods: We conducted a Randomized Controlled Trial (RCT) to investigate the effects of the DCP in 46 nursing home residents who needed high levels of nursing care. The participants were randomly assigned to an intervention and control group. The intervention group attended 30 min of the DCP thrice a week for 3 months. Cognitive function was measured using the Mini-Mental State Examination-Japanese (MMSE-J) and Frontal Assessment Battery (FAB). Physical function was measured using grip strength and active upper limb range of motion with the dominant hand. Body composition was measured using bioelectrical impedance analysis (BIA). These measures were analyzed before and after the DCP intervention period, and data for the two groups were compared thereafter. Results: Initially, the participants had low scores on the MMSE-J, and 84.78% of them used wheelchairs. Following the DCP intervention, the MMSE-J and FAB scores of the DCP group improved significantly. In terms of motor function, the active range of motion of the wrist palmar and the shoulder flexion improved in the intervention group. Regarding body composition, the skeletal muscle mass index, total body protein, and the dominant hand muscle mass that was adding physical load decreased. Conclusions: The DCP provided the participants with an opportunity to engage in continued exercise for 3 months. The intervention group exhibited improved cognitive function and upper limb motion range, and changes in body composition. The results suggest that DCP can be used as an intervention method to promote exercise and improve various health and cognitive functions. Trial Registration: This trial was registered at the University Hospital Medical Information Network Clinical Trial Registry (UMIN000024714) on 4 November 2016. The URL is available at https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000028399.

Non-invasive Brain Stimulation in Alzheimer's Disease and Mild Cognitive Impairment-A State-of-the-Art Review on Methodological Characteristics and Stimulation Parameters

Background: Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) have been proposed as a new therapeutic way to enhance the cognition of patients with dementia. However, serious methodological limitations appear to affect the estimates of their efficacy. We reviewed the stimulation parameters and methods of studies that used TMS or tDCS to alleviate the cognitive symptoms of patients with Alzheimer's disease (AD) and mild cognitive impairment (MCI). Moreover, we evaluated the risk of bias in these studies. Our aim was to highlight the current vulnerabilities of the field and to formulate recommendations on how to manage these issues when designing studies.

Methods: Electronic databases and citation searching were used to identify studies administering TMS or tDCS on patients with AD or MCI to enhance cognitive function. Data were extracted by one review author into summary tables with the supervision of the authors. The risk of bias analysis of randomized-controlled trials was conducted by two independent assessors with version 2 of the Cochrane risk-of-bias tool for randomized trials.

Results: Overall, 36 trials were identified of which 23 randomized-controlled trials underwent a risk of bias assessment. More than 75% of randomized-controlled trials involved some levels of bias in at least one domain. Stimulation parameters were highly variable with some ranges of effectiveness emerging. Studies with low risk of bias indicated TMS to be potentially effective for patients with AD or MCI while questioned the efficacy of tDCS.

Conclusions: The presence and extent of methodical issues affecting TMS and tDCS research involving patients with AD and MCI were examined for the first time. The risk of bias frequently affected the domains of the randomization process and selection of the reported data while missing outcome was rare. Unclear reporting was present involving randomization, allocation concealment, and blinding. Methodological awareness can potentially reduce the high variability of the estimates regarding the effectiveness of TMS and tDCS. Studies with low risk of bias delineate a range within TMS parameters seem to be effective but question the efficacy of tDCS.

What nursing home environment can maximise eating independence among residents with cognitive impairment? Findings from a secondary analysis

To explore the influence of the Nursing Home (NH) environment on eating independence while taking into account individual and nursing care factors, was the aim of the study. A secondary analysis was performed based on data collected in a multicentre prospective observational study involving 13 NHs. Residents aged >65 were included (n = 1,027). Dependence in eating was measured using the Edinburgh Feeding Evaluation in Dementia scale (EdFED, range 0-20). In addition to individual and nursing care variables, the NHs environments were assessed with the Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH, range 0-149). The mean EdFED score was 2.48 (95% Confidence Interval [CI]=2.22-2.73) and the TESS-NH score was 122.19 (95% CI=115.89-128.49). A linear regression analysis explained 30.8% of the total variance in eating dependence. Alongside individual and nursing care factors, in poor NH unit environments, residents with severe cognitive impairment showed increased eating dependence; in contrast, in better environments, similar residents showed maximal eating performance.

Memory complaints inventory profiles: Differentiating neurocognitive impairment, depression, and non-credible performance

The Memory Complaints Inventory (MCI) is a symptom validity measure designed to assess exaggerated memory complaints. The aim of current study was to develop memory complaint profiles on the MCI to distinguish between various neurocognitive disorders, depression, and non-credible performance. This study utilized MCI scores (N = 244) from a neuropsychology clinic to determine the presence of, and difference between, subjective memory complaints between a depression group, non-credible group, and subgroups of cognitive impairment (Alzheimer's Dementia, Vascular Dementia, and Mild Cognitive Impairment). Significant differences were found on MCI endorsement between cognitive impairment, depression, and non-credible groups. This pattern indicated fewer memory complaints for cognitive impairment groups when compared to depression and non-credible groups; the non-credible group had the highest MCI scores overall. ROC analyses revealed recommended clinical cutoff values with high specificity for distinguishing between the non-credible group and other groups. The findings provided further evidence for the MCI as a symptom validity measure, given its ability to differentiate between a non-credible group and clinical groups. Replication of the study's findings would result in reliable genuine subjective memory complaint profiles to provide additional diagnostic and prognostic specificity in neuropsychological practice.

Evaluating a young-onset dementia service from two sides of the coin: staff and service user perspectives

Background

People with young-onset dementia (YOD) can often struggle getting the right treatment. This is because of their frequently different characteristics and needs compared to people with late-onset dementia. The aim of this project was to assess a memory service for its adaptation to the needs and wishes of people with YOD and their carers.

Methods

This project evaluated a memory service in the North West of England by performing two focus groups with clinical staff and six semi-structured interviews with people with YOD and carers. The focus groups took place on site and lasted one hour each. People with YOD and their carers were identified via the memory clinics caseload and via the local Alzheimer’s Society charity organisation. Both focus groups and interviews were audio-recorded and transcribed, and data were analysed using thematic analysis. The public (a person living with YOD and his carer) were involved from the design stages of the project through to the analysis and dissemination.

Results

Eleven members of staff with different clinical backgrounds participated in the focus groups and six interviews were held with people with YOD and their carers. Both indicated that whilst the diagnostic process is relatively well conducted at the service, the post-diagnostic service has many gaps. These include limited post-diagnostic support by the service, better enabling peer support, as well as providing meaningful activities, as some activities provided might be more suitable to older adults with dementia.

Conclusions

Post-diagnostic services and support for people with YOD and their carers need to be improved. The next step will be to implement the findings from this service evaluation in practice and improve service satisfaction and relevance to people with YOD.

Neurovascular and Cognitive Dysfunction in Hypertension

Hypertension has emerged as a leading cause of age-related cognitive impairment. Long known to be associated with dementia caused by vascular factors, hypertension has more recently been linked also to Alzheimer disease-the major cause of dementia in older people. Thus, although midlife hypertension is a risk factor for late-life dementia, hypertension may also promote the neurodegenerative pathology underlying Alzheimer disease. The mechanistic bases of these harmful effects remain to be established. Hypertension is well known to alter in the structure and function of cerebral blood vessels, but how these cerebrovascular effects lead to cognitive impairment and promote Alzheimer disease pathology is not well understood. Furthermore, critical questions also concern whether treatment of hypertension prevents cognitive impairment, the blood pressure threshold for treatment, and the antihypertensive agents to be used. Recent advances in neurovascular biology, epidemiology, brain imaging, and biomarker development have started to provide new insights into these critical issues. In this review, we will examine the progress made to date, and, after a critical evaluation of the evidence, we will highlight questions still outstanding and seek to provide a path forward for future studies.

End Stage Clinical Features and Cause of Death of Behavioral Variant Frontotemporal Dementia and Young-Onset Alzheimer's Disease

BACKGROUND

Limited literature exists regarding the clinical features of end stage behavioral variant frontotemporal dementia (bvFTD). This data is indispensable to inform and prepare family members as well as professional caregivers for the expected disease course and to anticipate with drug-based and non-pharmacological treatment strategies.

OBJECTIVE

The aim of the present study was to describe end stage bvFTD in a broad explorative manner and to subsequently evaluate similarities and dissimilarities with the end stage of the most prevalent form of young-onset dementia, Alzheimer's disease (yoAD).

METHODS

We analyzed medical files on patients, using a mixed model of qualitative and quantitative approaches. Included were previously deceased patients with probable bvFTD and probable yoAD. End stage was defined as the last 6 months prior to death. Primary outcome measures comprised somatic, neurological, and psychiatric symptoms and the secondary outcome measure was cause of death.

RESULTS

Out of 89 patients, a total of 30 patients were included (bvFTD; n = 12, yoAD; n = 18). Overall, the end stages of bvFTD and yoAD were characterized by a broad spectrum of clinical symptoms including severe autonomic dysfunction and an increased muscle tone. Patients with bvFTD displayed more mutism compared with yoAD while compulsiveness was only present in bvFTD.

CONCLUSION

Our study describes the full clinical spectrum of end stage bvFTD and yoAD. In this study, symptoms extend far beyond the initial behavioral and cognitive features. By taking both somatic, psychiatric, and neurological features into account, family members and professional caregivers may anticipate (non) pharmacological treatment.

Association of Longitudinal β-Amyloid Accumulation Determined by Positron Emission Tomography With Clinical and Cognitive Decline in Adults With Probable Lewy Body Dementia

IMPORTANCE

In patients with probable dementia with Lewy bodies (DLB), overlapping Alzheimer disease pathology is frequent and is associated with faster decline and shorter survival. More than half of patients with DLB have elevated β-amyloid levels on carbon-11 labeled Pittsburgh compound B (PiB) positron emission tomography, but the trajectory of longitudinal β-amyloid accumulation and its associations with clinical and cognitive decline in DLB are not known.

OBJECTIVES

To determine the trajectory of β-amyloid accumulation in patients with probable DLB and to investigate the associations of β-amyloid accumulation with measures of clinical and cognitive decline over time in DLB.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 35 consecutive patients with probable DLB from the Mayo Clinic Alzheimer Disease Research Center and matched them by age, sex, and apolipoprotein e4 status with 140 cognitively unimpaired participants from the population-based Mayo Clinic Study of Aging. Participants were observed from April 2010 to September 2017. Data analysis was conducted from January 2018 to January 2019.

EXPOSURE

Baseline and follow-up PiB positron emission tomography and comprehensive clinical evaluations.

MAIN OUTCOMES AND MEASURES

Rate of change in PiB standardized uptake value ratios (SUVRs) by PiB SUVR and time in years; the associations between baseline PiB SUVR, change in PiB SUVR, and change in several measures of clinical and cognitive decline.

RESULTS

A total of 175 participants were evaluated (35 [20.0%] with probable DLB; mean [SD] age, 69.6 [7.3] years; 16 [45.7%] apolipoprotein e4 carriers; 31 [88.6%] men; and 140 [80.0%] cognitively unimpaired adults; mean [SD] age, 69.7 [7.2] years; 64 [45.7%] apolipoprotein e4 carriers; 124 [88.6%] men). In both groups, the rates of change in PiB SUVR showed an initial acceleration at lower baseline PiB SUVR followed by a deceleration at higher baseline PiB SUVR, thus forming an inverted-U shape. The trajectories of the rates of change in PiB SUVR did not differ between participants with probable DLB and cognitively unimpaired participants in terms of shape (P = .59) or vertical shift (coefficient [SE] 0.007 [0.006]; P = .22). The integral association of cumulative PiB SUVR with time in years showed a sigmoid-shaped functional form in both groups. In participants with probable DLB, higher baseline PiB SUVR and change in PiB SUVR were associated with more rapid clinical decline, as measured by the Clinical Dementia Rating, sum of boxes (baseline PiB SUVR: regression coefficient [SE], 1.90 [0.63]; P = .005; R2 = 0.215; change in PiB SUVR, regression coefficient [SE], 16.17 [7.47]; P = .04; R2 = 0.124) and the Auditory Verbal Learning Test, delayed recall (baseline PiB SUVR, regression coefficient [SE], -2.09 [0.95]; P = .04; R2 = 0.182; change in PiB SUVR, regression coefficient [SE], -25.05 [10.04]; P = .02; R2 = 0.221).

CONCLUSIONS AND RELEVANCE

In this study, the rate of change in PiB SUVR among participants with probable DLB increased, peaked, and then decreased, which was similar to the trajectory in cognitively unimpaired participants and the Alzheimer disease dementia continuum. Higher baseline PiB SUVR and change in PiB SUVR were associated with more rapid clinical and cognitive decline over time. Measuring the change in PiB SUVR has implications for designing anti-β-amyloid randomized clinical trials for individuals with probable DLB.

Burden of Disease and Current Management of Dementia with Lewy Bodies: A Literature Review

INTRODUCTION

A significant proportion of dementia is concretely estimated to be attributable to dementia with Lewy bodies (DLB)-one of the most common types of progressive dementia; however, there is a paucity of literature on this disease. We aimed to examine available evidence to gain a better understanding of its treatment landscape, clinical management, and disease burden.

METHODS

A systematic literature review captured any DLB studies that report on randomised controlled trials (RCTs), epidemiology, disease progression, and economic data. An additional targeted literature review captured studies reporting on clinical management and quality of life (QoL) in this disease. Publication date was limited to 1 January 2007-26 March 2018, with the exception for RCTs, where no time restrictions were applied.

FINDINGS

Of the 3486 studies initially identified, 55 studies were eligible for inclusion. The studies were mainly from Europe (n = 29), the USA (n = 9), and Japan (n = 8). Mini-Mental State Examination and Neuropsychiatric Inventory scores were the most commonly reported clinical outcomes in RCTs (n = 14). The most frequently identified interventions reported in RCTs were donepezil and memantine. Patients with DLB typically reported worse outcomes in relation to efficacy and safety, cognitive impairment, survival, and QoL compared with those with Alzheimer's disease (AD). Additionally, patients with DLB were associated with higher hospitalisation rates and cost of care. Furthermore, there is a reliance on a small number of consensus guidelines. Of these, only one set of guidelines (DLB Consortium) was developed specifically for DLB.

CONCLUSION

The paucity of data indicates an unmet need in this therapy area. Although several studies look into the clinical and pathological aspects of DLB, consensus guidelines and studies on healthcare utilisation in patients with dementia have largely focused on AD. Additionally, most of the findings were made in comparison with AD.

FUNDING

Eisai Inc.

Memory Complaint Is a Surrogate for Memory Decline in the Middle-Aged: A Register-Based Study

Memory complaint is one of the earliest symptoms of dementia. The causes and prognosis of memory complaint in the middle-aged population remain largely unknown. We reviewed the register-based data of 2129 patients with memory complaints. Among them, 404 participants were between 40 and 65 years old. The participants were separated into three groups: subjective cognitive decline (SCD), neurodegenerative diseases (ND), and non-neurodegenerative diseases (NND). One-year decline was defined as a decrease of ≥1 on the mini-mental state examination (MMSE). At baseline, 131 participants (32%) were diagnosed with SCD, 141 (35%) with ND, and 132 (33%) with NND. The 1-year cognitive decline rate was higher among patients with ND (36.8%) than in the SCD (7.3%, p = 1.3 × 10⁻⁸) and NND groups (7.6%, p = 1.1 × 10⁻⁷). One-year decline did not differ between the SCD and NND groups. Lower baseline MMSE score predicted increased risk of 1-year cognitive decline (odds ratio (OR) = 1.126, 95% confidence interval (CI) = 1.076–1.178, p = 2.52 × 10⁻⁷). Memory complaint in middle age carried a risk of 1-year cognitive decline, and baseline MMSE is an independent predictor of decline. An initial diagnosis of SCD held the same risk effect for decline as NND. These findings highlighted the necessity for neuropsychological tests in those with memory complaints presenting to the clinic.

Are loneliness and social isolation associated with cognitive decline?

OBJECTIVE

This study aimed to examine the association of loneliness and social isolation on cognition over a 3-year follow-up period in middle- and older-aged adults.

METHODS

Data from a Spanish nationally representative sample were analyzed (n = 1691; aged 50 years or older). Loneliness, social isolation, and cognition (immediate recall, delayed recall, verbal fluency, forward digit span, backward digit span, and a composite cognitive score) were assessed both at baseline and at follow-up. Adjusted generalized estimating equations models were performed.

RESULTS

Loneliness was significantly associated with lower scores in the composite cognitive score, immediate and delayed recall, verbal fluency, and backward digit span (B = -0.14 to B = -3.16; P < .05) and with a more rapid decline from baseline to follow-up in two out of six cognitive tests. Higher social isolation was associated with lower scores in the composite cognitive score, verbal fluency, and forward digit span (B = -0.06 to B = -0.85; P < .05). The effect of loneliness and social isolation on cognition remained significant after the exclusion of individuals with depression.

CONCLUSIONS

Both loneliness and social isolation are associated with decreased cognitive function over a 3-year follow-up period. The development of interventions that include the enhancement of social participation and the maintenance of emotionally supportive relationships might contribute to cognitive decline prevention and risk reduction.

Differentiating between dementia, delirium and depression in older people

Older people can find hospital stays challenging and distressing. When their presenting symptoms make it challenging for healthcare professionals to differentiate between dementia, delirium and depression, their experience may be increasingly distressing, and can result in delays in diagnosis and treatment, as well as an increased risk of morbidity. This article considers each of the conditions of dementia, delirium and depression, their presenting features and how nurses can differentiate between them to enable comprehensive assessment, diagnosis and treatment in older people.

Quantitative and qualitative features of executive dysfunction in frontotemporal and Alzheimer's dementia

Behavioral variant fronto-temporal degeneration (bvFTD) is typically distinguished from Alzheimer's disease (AD) by early, prominent dysexecutive findings, in addition to other clinical features. However, differences in executive functioning between these groups are not consistently found. The current study sought to investigate quantitative and qualitative differences in executive functioning between those with bvFTD and AD in a large sample, while controlling for dementia severity and demographic variables. Secondary data analyses were completed on a subset of cases from the National Alzheimer's Coordinating Center collected from 36 Alzheimer's Disease Research Centers and consisting of 1,577 individuals with AD and 406 individuals with bvFTD. Groups were compared on 1) ability to complete three commonly administered executive tasks (letter fluency, Trail Making Test Part B [TMTB], and digits backward); 2) quantitative test performance; and 3) errors on these tasks. Findings suggested that individuals with bvFTD were less likely to complete letter fluency, χ²(2) = 178.62, p < .001, and number span tasks, χ²(1) = 11.49, p < .001), whereas individuals with AD were less likely to complete TMTB, χ²(2) = 460.38, p < .001. Individuals with bvFTD performed more poorly on letter fluency, F(1) = 28.06, p = .013, but there were not group differences in TMTB lines per second or number span backwards. Errors generally did not differentiate the diagnostic groups. In summary, there is substantial overlap in executive dysfunction between those with bvFTD and AD, though individuals with bvFTD tend to demonstrate worse letter fluency performance.

A Systematic Review on the Possible Relationship Between Bilingualism, Cognitive Decline, and the Onset of Dementia

A systematic review was conducted to investigate whether bilingualism has a protective effect against cognitive decline in aging and can protect against dementia. We searched the Medline, ScienceDirect, Scopus, and ERIC databases with a cut-off date of 31 March 2019, thereby following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocol. Our search resulted in 34 eligible studies. Mixed results were found with respect to the protective effect of bilingualism against cognitive decline. Several studies showed a protective effect whereas other studies failed to find it. Moreover, evidence for a delay of the onset of dementia of between 4 and 5.5 years in bilingual individuals compared to monolinguals was found in several studies, but not in all. Methodological differences in the set-up of the studies seem to explain these mixed results. Lifelong bilingualism is a complex individual process, and many factors seem to influence this and need to be further investigated. This can be best achieved through large longitudinal studies with objective behavioral and neuroimaging measurements. In conclusion, although some evidence was found for a cognitive reserve-enhancing effect of lifelong bilingualism and protection against dementia, to date, no firm conclusions can be drawn.