Insight for impairment in independent living skills in Alzheimer's disease and multi-infarct dementia

Exploratory study of French healthcare workers' experiences of anosognosia in Alzheimer's disease and related disorders

BACKGROUND

Anosognosia or lack of insight is a common feature of Alzheimer's disease (AD) and associated disorders. It is an impairment in the ability to recognize the disease and related symptoms. Anosognosia is associated among patients with poor compensatory strategies, behavioral disorders, apathy and caregiver burden. Therefore, its early identification by healthcare workers is a major challenge in order to provide support for both patients and caregivers.

OBJECTIVE

To explore the knowledge, attitudes and experiences of French healthcare workers relating to anosognosia in AD and related disorders.

METHODS

An online self-completed questionnaire was created for the study. It was anonymous and divided into three dimensions: general knowledge, confidence, and subjective experiences of anosognosia. One hundred and eleven healthcare workers completed the questionnaire. Mann Whitney and Kruskal Wallis tests were used to determine the variables associated with the total knowledge and confidence scores. Ordinal logistic regressions were performed to explore the associations between subjective experiences and demographics.

RESULTS

The participants had moderate knowledge. Knowledge scores were influenced by their experience in the geriatric field, type of profession, workplaces and training. The areas where knowledge was poorest were anosognosia assessment and management. The participants with the lowest knowledge levels were those interacting the most with patients, especially at home. Overall, they identified difficulties related to anosognosia and did not seem confident about their ability to deal with this condition.

CONCLUSIONS

This study determines specific areas for training on anosognosia, such as identification, assessment and management of this condition.

Exploring the link between tooth loss, cognitive function, and brain wellness in the context of healthy aging

AIMS

The aim of this study was to evaluate the utility of using MRI-derived tooth count, an indirect and nonspecific indicator of oral/periodontal health, and brain age gap (BAG), an MRI-based measure of premature brain aging, in predicting cognition in a population of otherwise healthy adults.

METHODS

This retrospective study utilized data from 329 participants from the University of South Carolina's Aging Brain Cohort Repository. Participants underwent neuropsychological testing including the Montreal Cognitive Assessment (MoCA), completed an oral/periodontal health questionnaire, and submitted to high-resolution structural MRI imaging. The study compared variability on cognitive scores (MoCA) accounted for by MRI-derived BAG, MRI-derived total tooth count, and self-reported oral/periodontal health.

RESULTS

We report a significant positive correlation between the total number of teeth and MoCA total scores after controlling for age, sex, and race, indicating a robust relationship between tooth count and cognition, r(208) = .233, p < .001. In a subsample of participants identified as being at risk for MCI (MoCA <= 25, N = 36) inclusion of MRI-based tooth count resulted in an R2 change of .192 (H0 = 0.138 → H1 = 0.330), F(1,31) = 8.86, p = .006. Notably, inclusion of BAG, a valid and reliable measure of overall brain health, did not significantly improve prediction of MoCA scores in similar linear regression models.

CONCLUSIONS

Our data support the idea that inclusion of MRI-based total tooth count may enhance the ability to predict clinically meaningful differences in cognitive abilities in healthy adults. This study contributes to the growing body of evidence linking oral/periodontal health with cognitive function.

[Conscience des déficits dans le cadre de la maladie d'Alzheimer : représentations et vécu des professionnels soignants]

La qualité des soins apportés aux personnes vivant avec la maladie d'Alzheimer (MA) dépend en partie de la capacité des professionnels à déterminer le degré de conscience de la maladie chez les patients. La présente recherche s'est intéressée aux représentations des soignants concernant la conscience des troubles chez les résidents d'établissements de soins de longue durée présentant un diagnostic de MA. Le pouvoir prédicteur de l'anosognosie sur le fardeau soignant a également été examiné. L'anosognosie des troubles de la construction (r = 0,40, p = 0,0164) et de l'initiation (r = 0,32, p = 0,052) était corrélée au fardeau soignant. Les professionnels se représentaient les résidents comme ayant une conscience altérée de leurs capacités, même en l'absence d'anosognosie. Les scores réels d'anosognosie ne prédisaient pas les estimations soignantes, hormis le score global sous forme de tendance (χ2 = 3,38, p = 0,066). Les soignants surestimaient pourtant les performances cognitives des résidents, telles que mesurées au moyen du protocole Misawareness (prédictions aidants/performances réelles : DC = 12,32, p < 0,0001).

Considerations for the use of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) in cross-country comparisons of cognitive aging and dementia

INTRODUCTION

Informant reports are a critical component of dementia diagnoses, but the comparability of informant reports across countries is not well understood.

METHODS

We compared the performance of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) using population-representative surveys in the United States (N = 3183), England (N = 1050), and India (N = 4047).

RESULTS

Analyses of regression splines and comparisons of model fit showed strong associations between IQCODE and objective cognition at low cognitive functioning in the United States and England; in India, the association was weaker but consistent over the range of cognition. Associations between IQCODE score and informant generation (analysis of variance [ANOVA] p = 0.001), caregiver status (p < 0.001), and years known by the informant (p = 0.015) were different across countries after adjusting for objective cognition.

DISCUSSION

In India, the IQCODE was less sensitive to impairments at the lowest levels of cognitive functioning. Country-specific adjustments to IQCODE scoring based on informant characteristics may improve cross-national comparisons.

HIGHLIGHTS

Associations between IQCODE and cognitive testing were similar in the United States and England but differed in India. In India, the IQCODE may be less sensitive to impairments among those with low cognition and no education. Informant characteristics may differentially impact informant reports of decline across countries. Adjustments or culturally sensitive adaptations may improve cross-national comparability.

Knowing "what for," but not "where": Dissociation between functional and contextual tool knowledge in healthy individuals and patients with dementia

OBJECTIVE

Semantic tool knowledge underlies the ability to perform activities of daily living. Models of apraxia have emphasized the role of functional knowledge about the action performed with tools (e.g., a hammer and a mallet allow a "hammering" action), and contextual knowledge informing individuals about where to find tools in the social space (e.g., a hammer and a mallet can be found in a workshop). The goal of this study was to test whether contextual or functional knowledge, would be central in the organization of tool knowledge. It was assumed that contextual knowledge would be more salient than functional knowledge for healthy controls and that patients with dementia would show impaired contextual knowledge.

METHODS

We created an original, open-ended categorization task with ambiguity, in which the same familiar tools could be matched on either contextual or functional criteria.

RESULTS

In our findings, healthy controls prioritized a contextual, over a functional criterion. Patients with dementia had normal visual categorization skills (as demonstrated by an original picture categorization task), yet they made less contextual, but more functional associations than healthy controls.

CONCLUSION

The findings support a dissociation between functional knowledge ("what for") on the one hand, and contextual knowledge ("where") on the other hand. While functional knowledge may be distributed across semantic and action-related factors, contextual knowledge may actually be the name of higher-order social norms applied to tool knowledge. These findings may encourage researchers to test both functional and contextual knowledge to diagnose semantic deficits and to use open-ended categorization tests.

Trajectories of cognitive and perceived functional decline in people with dementia: Findings from the IDEAL programme

INTRODUCTION

Impaired cognition and instrumental activities of daily living (iADL) are key diagnostic features of dementia; however, few studies have compared trajectories of cognition and iADL.

METHODS

Participants from the IDEAL study comprised 1537, 1183, and 851 people with dementia, and 1277, 977, and 749 caregivers at baseline, 12 and 24 months, respectively. Addenbrooke's Cognitive Examination-III and Functional Activities Questionnaire were used to measure cognition and iADL, respectively. Scores were converted to deciles.

RESULTS

Self-rated iADL declined on average by -0.08 (-0.25, 0.08) decile points per timepoint more than cognition. Informant-rated iADL declined on average by -0.31 (-0.43, -0.18) decile points per timepoint more than cognition.

DISCUSSION

Cognition and self-rated iADL declined at a similar rate. Informant-rated iADL declined at a significantly greater rate than cognition. Therefore, either cognition and perceived iADL decline at different rates or informants overestimate increasing iADL difficulties compared to both cognition and self-ratings.

HIGHLIGHTS

Self-ratings of the degree of functional difficulties were consistent with cognition Decline in self-rated everyday activities was consistent with cognitive decline Informant-ratings of everyday activities declined more than cognition.

Effects of the visual environment on object localization in posterior cortical atrophy and typical Alzheimer's disease

Introduction

Visual processing deficits in Alzheimer's disease are associated with diminished functional independence. While environmental adaptations have been proposed to promote independence, recent guidance gives limited consideration to such deficits and offers conflicting recommendations for people with dementia. We evaluated the effects of clutter and color contrasts on performances of everyday actions in posterior cortical atrophy and memory-led typical Alzheimer's disease.

Methods

15 patients with posterior cortical atrophy, 11 with typical Alzheimer's disease and 16 healthy controls were asked to pick up a visible target object as part of two pilot repeated-measures investigations from a standing or seated position. Participants picked up the target within a controlled real-world setting under varying environmental conditions: with/without clutter, with/without color contrast cue and far/near target position. Task completion time was recorded using a target-mounted inertial measurement unit.

Results

Across both experiments, difficulties locating a target object were apparent through patient groups taking an estimated 50-90% longer to pick up targets relative to controls. There was no evidence of effects of color contrast when locating objects from standing/seated positions and of any other environmental conditions from a standing position on completion time in any participant group. Locating objects, surrounded by five distractors rather than none, from a seated position was associated with a disproportionately greater effect on completion times in the posterior cortical atrophy group relative to the control or typical Alzheimer's disease groups. Smaller, not statistically significant but directionally consistent, ratios of relative effects were seen for two distractors compared with none.

Discussion

Findings are consistent with inefficient object localization in posterior cortical atrophy relative to typical Alzheimer's disease and control groups, particularly with targets presented within reaching distance among visual clutter. Findings may carry implications for considering the adverse effects of visual clutter in developing and implementing environmental modifications to promote functional independence in Alzheimer's disease.

The role of dyadic cognitive report and subjective cognitive decline in early ADRD clinical research and trials: Current knowledge, gaps, and recommendations

Efficient identification of cognitive decline and Alzheimer's disease (AD) risk in early stages of the AD disease continuum is a critical unmet need. Subjective cognitive decline is increasingly recognized as an early symptomatic stage of AD. Dyadic cognitive report, including subjective cognitive complaints (SCC) from a participant and an informant/study partner who knows the participant well, represents an accurate, reliable, and efficient source of data for assessing risk. However, the separate and combined contributions of self- and study partner report, and the dynamic relationship between the two, remains unclear. The Subjective Cognitive Decline Professional Interest Area within the Alzheimer's Association International Society to Advance Alzheimer's Research and Treatment convened a working group focused on dyadic patterns of subjective report. Group members identified aspects of dyadic-report information important to the AD research field, gaps in knowledge, and recommendations. By reviewing existing data on this topic, we found evidence that dyadic measures are associated with objective measures of cognition and provide unique information in preclinical and prodromal AD about disease stage and progression and AD biomarker status. External factors including dyad (participant-study partner pair) relationship and sociocultural factors contribute to these associations. We recommend greater dyad report use in research settings to identify AD risk. Priority areas for future research include (1) elucidation of the contributions of demographic and sociocultural factors, dyad type, and dyad relationship to dyad report; (2) exploration of agreement and discordance between self- and study partner report across the AD syndromic and disease continuum; (3) identification of domains (e.g., memory, executive function, neuropsychiatric) that predict AD risk outcomes and differentiate cognitive impairment due to AD from other impairment; (4) development of best practices for study partner engagement; (5) exploration of study partner report as AD clinical trial endpoints; (6) continued development, validation, and optimization, of study partner report instruments tailored to the goals of the research and population.

Predictors of Awareness of Functional Ability in People with Dementia: The Contribution of Personality, Cognition, and Neuropsychiatric Symptoms - Findings from the IDEAL Program

INTRODUCTION

Discrepancy scores reflecting the difference between parallel ratings made by people living with dementia (PwD) in the mild-to-moderate stages and by their informants provide a way to investigate awareness of functional ability in relation to activities of daily living (ADL).

METHODS

Two measures of ADL (Functional Activities Questionnaire; Dependence Scale) were completed by 1,227 PwD and their informants in the IDEAL cohort study baseline assessment. Self-rated and informant-rated scores were used to calculate discrepancies, which were used as an indicator of awareness of functional ability. Smaller discrepancy scores were considered to reflect greater awareness on the part of PwD. PwD completed questionnaires on depression, personality, comorbidities, neuropsychiatric symptoms, and completed a measure of cognition. Informants provided ratings of stress. Univariable and multiple regressions were used to investigate factors related to ADL discrepancy.

RESULTS

A similar pattern of associations were found for both ADL discrepancy scores. Smaller discrepancy scores were associated with higher levels of depression, higher neuroticism, fewer neuropsychiatric symptoms, higher comorbidity, lower carer stress, and receipt of less than 1 hour of care per day from the informant.

DISCUSSION/CONCLUSION

There was a clear pattern of factors that were associated with greater awareness for both measures of functional ability. These factors associated with smaller discrepancy scores could be used to identify PwD who might benefit from targeted interventions to support their independence.

Everyday Functioning in a Community-Based Volunteer Population: Differences Between Participant- and Study Partner-Report

Introduction: Impaired awareness in dementia caused by Alzheimer's disease and related disorders made study partner-report the preferred method of measuring interference in "instrumental activities of daily living" (IADL). However, with a shifting focus toward earlier disease stages and prevention, the question arises whether self-report might be equally or even more appropriate. The aim of this study was to investigate how participant- and study partner-report IADL perform in a community-based volunteer population without dementia and which factors relate to differences between participant- and study partner-report. Methods: Participants (N = 3,288; 18-97 years, 70.4% females) and their study partners (N = 1,213; 18-88 years, 45.8% females) were recruited from the Dutch Brain Research Registry. IADL were measured using the Amsterdam IADL Questionnaire. The concordance between participant- and study partner-reported IADL difficulties was examined using intraclass correlation coefficient (ICC). Multinomial logistic regressions were used to investigate which demographic, cognitive, and psychosocial factors related to participant and study partner differences, by looking at the over- and underreport of IADL difficulties by the participant, relative to their study partner. Results: Most A-IADL-Q scores represented no difficulties for both participants (87.9%) and study partners (89.4%). The concordance between participants and study partners was moderate (ICC = 0.55, 95% confidence interval [CI] = [0.51, 0.59]); 24.5% (N = 297) of participants overreported their IADL difficulties compared with study partners, and 17.8% (N = 216) underreported difficulties. The presence of depressive symptoms (odds ratio [OR] = 1.31, 95% CI = [1.12, 1.54]), as well as memory complaints (OR = 2.45, 95% CI = [1.80, 3.34]), increased the odds of participants overreporting their IADL difficulties. Higher IADL ratings decreased the odds of participant underreport (OR = 0.71, 95% CI = [0.67, 0.74]). Conclusion: In this sample of community-based volunteers, most participants and study partners reported no major IADL difficulties. Differences between participant and study partner were, however, quite prevalent, with subjective factors indicative of increased report of IADL difficulties by the participant in particular. These findings suggest that self- and study partner-report measures may not be interchangeable, and that the level of awareness needs to be considered, even in cognitively healthy individuals.

Subtle mistakes in self-report surveys predict future transition to dementia

INTRODUCTION

We investigate whether indices of subtle reporting mistakes derived from responses in self-report surveys are associated with dementia risk.

METHODS

We examined 13,831 participants without dementia from the prospective, population-based Health and Retirement Study (mean age 69 ± 10 years, 59% women). Participants' response patterns in 21 questionnaires were analyzed to identify implausible responses (multivariate outliers), incompatible responses (Guttman errors), acquiescent responses, random errors, and the proportion of skipped questions. Subsequent incident dementia was determined over up to 10 years of follow-up.

RESULTS

During follow-up, 2074 participants developed dementia and 3717 died. Each of the survey response indices was associated with future dementia risk controlling for confounders and accounting for death as a competing risk. Stronger associations were evident for participants who were younger and cognitively normal at baseline.

DISCUSSION

Mistakes in the completion of self-report surveys in longitudinal studies may be early indicators of dementia among middle-aged and older adults.

Measuring Awareness in People With Dementia: Results of a Systematic Scoping Review

BACKGROUND

Awareness of the diagnosis or related changes in functioning varies in people with dementia (PwD), with implications for the well-being of PwD and their carers. Measuring awareness in a clinical setting could facilitate tailored support and optimize involvement in personal health and care decisions. This scoping review aimed to identify validated methods of assessing awareness in dementia and appraise their clinical utility.

METHOD

A systematic search was conducted of English-language publications that measured awareness in PwD, in 6 electronic databases. Search terms included dement*, Alzheimer*, Pick disease, and awareness, unawareness, anosognosia, insight, denial, metacognit*, or discrepanc*.

RESULTS

We screened 30,634 articles, finding 345 articles that met our inclusion criteria. We identified 76 measures, most commonly using a discrepancy questionnaire comparing evaluations of function by PwD and an informant. There were 30 awareness measures developed and validated for use in dementia populations but few designed for general clinical use.

CONCLUSIONS

Although we found a range of clinical indications for measuring awareness, there were few studies investigating clinical applications and few tools designed for clinical purposes. Further investigation and development of a person-centered tool could facilitate health and care choices in mild-to-moderate dementia.

Structural Gray and White Matter Correlates of Awareness in Alzheimer's Disease

BACKGROUND

Unawareness of disease is a common feature of Alzheimer's disease (AD), but few studies explored its neural correlates. Additionally, neural correlates according to the object of awareness are unexplored.

OBJECTIVE

To investigate structural brain correlates in relation to different objects of awareness.

METHODS

27 people with AD underwent MRI scanning on a 3T Siemens Prisma. T1-MPRAGE was used to investigate cortical thickness and white matter microstructure was defined by DTI as fractional anisotropy, mean, axial, and radial diffusivity. Preprocessing used FreeSurfer6.0, ExploreDTI, and FSL-TBSS. Awareness of disease, cognitive deficits, emotional state, relationships, and functional capacity were assessed with the short version of the Assessment Scale of Psychosocial Impact of the Diagnosis of Dementia. Voxel-wise correlations between brain structure and awareness were determined by FSL-PALM. Analyses were corrected for multiple comparisons using Threshold Free Cluster Enhancement and FWE.

RESULTS

Lower left hemisphere cortical thickness was related to poorer disease awareness uncorrected and corrected for age, sex, and MMSE. In the uncorrected model, mainly right-sided, but also left temporal lower cortical thickness was related to decreased awareness of cognitive deficits. Correcting for age, sex, and MMSE eliminated correlations for the right hemisphere, but extensive correlations in the left hemisphere remained. For white matter integrity, higher right hemisphere MD was related to lower cognitive awareness deficits, and lower FA was related to lower functional capacity awareness.

CONCLUSION

Findings suggest that extensive regions of the brain are linked to self-awareness, with particular frontal and temporal alterations leading to unawareness, in agreement with theoretical models indicating executive and mnemonic forms of anosognosia in AD.

Mild cognitive impairment history and current procedures in low- and middle-income countries: a brief review

Mild cognitive impairment (MCI) is a widely studied concept that has changed over time. Epidemiology, diagnosis, costs, prognostics, screening procedures, and categorization have been extensively discussed. However, unified guidelines are still not available, especially considering differences between low- and middle-income countries (LMIC) and high-income countries (HIC).

Validation of the Korean Version of the Anosognosia Questionnaire for Dementia

OBJECTIVE

Anosognosia is a common phenomenon in individuals with dementia. Anosognosia Questionnaire for dementia (AQ-D) is a well-known scale for evaluating anosognosia. This study aimed to establish a Korean version of the AQ-D (AQ-D-K) and to evaluate the reliability and validity of the AQ-D-K in patients with Alzheimer's disease (AD) dementia.

METHODS

We translated the original English version of AQ-D into Korean (AQ-D-K). Eighty-four subjects with very mild or mild AD dementia and their caregivers participated. Reliability of AQ-D-K was assessed by internal consistency and one-month test-retest reliability. Construct validity and concurrent validity were also evaluated.

RESULTS

Internal consistencies of the AQ-D-K patient form and caregiver form were high (Cronbach alpha 0.95 and 0.93, respectively). The test-retest reliability of AQ-D-K measured by intra-class correlation coefficient was 0.84. Three factors were identified: 1) anosognosia of instrumental activity of daily living; 2) anosognosia basic activity of daily living; and 3) anosognosia of depression and disinhibition. AQ-D-K score was significantly correlated with the clinician-rated anosognosia rating scale (ARS), center for epidemiological studies-depression scale (CES-D) and state-trait anxiety inventory (STAI).

CONCLUSION

The findings suggest that the AQ-D-K is a reliable and valid scale for evaluating anosognosia for AD dementia patients using Korean language.

The Clinical Utility and Ecological Validity of the Medication Management Ability Assessment in Older Adults with and without Dementia

OBJECTIVE

Older adults are susceptible to medication nonadherence, which may signify functional decline. Thus, performance-based proxies of medication-taking behavior may help diagnose dementia. We assessed the Medication Management Ability Assessment's (MMAA) clinical utility and ecological validity.

METHOD

This was a retrospective chart review of 180 outpatients (age = 72 ± 8 years) who completed the MMAA during clinical evaluations. Forty-seven were cognitively normal (CN), 103 had mild cognitive impairment (MCI), and 30 had dementia. Most (136) were independent in medication management, whereas 28 were assisted and 16 were dependent. Kruskal-Wallis tests assessed whether MMAA scores differed by diagnosis and independence. Receiver operating characteristic (ROC) analyses identified diagnostic cut-offs. Classification accuracy estimates were derived.

RESULTS

MMAA performance differed across diagnosis as expected (p's < .001). Those who were independent in medication management outperformed assisted and dependent counterparts (p's < .001). Assisted and dependent cases were no different. At a cut-off = 23, the MMAA was good-to-strong in distinguishing dementia from CN cases (Sn = 0.96, Sp = 0.83), dementia from MCI (Sn = 0.70, Sp = 0.83), and dementia from functionally unimpaired cases (Sn = 0.78, Sp = 0.83). At a cut-off = 27, it had good sensitivity but weaker specificity when distinguishing both MCI and all cognitively impaired patients (MCI and dementia) from CN cases (Sn = 0.81, Sp = 0.66 and Sn = 0.81, Sp = 0.72, respectively).

CONCLUSIONS

The MMAA has ecological validity and clinical utility in identifying dementia. Its inclusion in neuropsychological practice may be especially useful when medication mismanagement is suspected.

The Association Between Impaired Awareness and Depression, Anxiety, and Apathy in Mild to Moderate Alzheimer's Disease: A Systematic Review

Objectives: Impaired awareness of cognitive and functional deficits is a common feature of Alzheimer's disease (AD). Although a lack of awareness has been suggested to be a protective factor against experiencing affective symptoms, such as depression, anxiety, and apathy which are common in AD, there is conflicting evidence about the links between them. This systematic review examines the evidence for an association between impaired awareness and depressive, anxiety, and apathy symptoms in mild to moderate AD. Method: We searched four databases (OvidMedline, Embase, PsycInfo, and PsycArticles) using terms encompassing awareness, apathy, depression, anxiety, and mild-moderate AD. We included studies that assessed the relationship between awareness and depressive symptoms, anxiety symptoms, or apathy. We assessed included papers for quality and report results using a narrative approach, prioritizing high quality studies. Results: We identified 1,544 articles, and twenty-seven studies fulfilled inclusion criteria (high-quality = 15; moderate-quality = 12). Most high-quality studies reported that impaired awareness in early-stage AD is cross-sectionally linked with fewer depressive symptoms and anxiety symptoms (correlation ranged from -0.3 to -0.7), but with more apathy. Conclusions: High-quality studies suggested that in people with early AD, impaired awareness is related to fewer depressive and anxiety symptoms and to more apathy. Future research should focus on elucidating causality among impaired awareness and these symptoms in AD.

Anosognosia in dementia: A review of current assessment instruments

INTRODUCTION

Anosognosia is a common but underrated symptom in dementia and has significant impact on both patients and caregivers. A proper evaluation of anosognosia is therefore desirable. There are three common methods to determine anosognosia: (1) clinical rating, (2) patient-caregiver discrepancies, and (3) prediction of performance discrepancies. Each of them includes different instruments. This review gives an overview of the current instruments used for the assessment of anosognosia in patients with dementia and aims to determine the most suitable instrument for routine use in clinical practice.

METHODS

A search of the literature in PubMed was performed. Furthermore, electronic databases (PsycINFo, ClinicalKey, and Cochrane Library) and reference lists were searched for additional articles.

RESULTS

Forty-six articles were included in this study, comprising 10 clinical rating instruments, 25 patient-caregiver discrepancy instruments, and 14 prediction-performance discrepancy instruments. For every publication, the aims of the study, the included population, the assessment instrument used, the assessed domains, and the psychometric properties of the assessment instruments are described.

CONCLUSIONS

Currently, there is no consensus on the most suitable method to determine anosognosia in dementia. We recommend the Clinical Insight Rating scale and the Abridged Anosognosia Questionnaire-Dementia as the most appropriate for routine use in clinical practice.

A French-Greek Cross-Site Comparison Study of the Use of Automatic Video Analyses for the Assessment of Autonomy in Dementia Patients

Background: At present, the assessment of autonomy in daily living activities, one of the key symptoms in Alzheimer’s disease (AD), involves clinical rating scales. Methods: In total, 109 participants were included. In particular, 11 participants during a pre-test in Nice, France, and 98 participants (27 AD, 38 mild cognitive impairment—MCI—and 33 healthy controls—HC) in Thessaloniki, Greece, carried out a standardized scenario consisting of several instrumental activities of daily living (IADLs), such as making a phone call or preparing a pillbox while being recorded. Data were processed by a platform of video signal analysis in order to extract kinematic parameters, detecting activities undertaken by the participant. Results: The video analysis data can be used to assess IADL task quality and provide clinicians with objective measurements of the patients’ performance. Furthermore, it reveals that the HC statistically significantly outperformed the MCI, which had better performance compared to the AD participants. Conclusions: Accurate activity recognition data for the analyses of the performance on IADL activities were obtained.

Distress in neurocognitive disorders due to Alzheimer's disease and stroke

Patients with neurocognitive disorders experience subjectively the concept of quality of life; this is the reason why researchers avoid approaching this concept and prefer to focus attention on the emotional profile of the caregivers. Many studies highlight the efforts both emotional and financial made by caregivers in case of patients diagnosed with neurocognitive disorders. The present study shows the differences between the patients diagnosed with neurocognitive disorder due to Alzheimer's disease and patients diagnosed with stroke, as well as the Romanian norms for the short form of Geriatric Depression Scale. The study group consisted of the clinical population (N=45), selected according to the inclusion/exclusion criteria, following the principles of Helsinki Declaration for Ethical Medical Research. The study was conducted at the Neuropsychiatry section of the Municipal Clinical Hospital, Dr Gavril Curteanu, Oradea, Romania. The results showed significant differences between the two types of patients in terms of quality of life, t(43)=-7.99, P=0.001, affective distress, t(43)=5.10, P=0.001 and perceived stress, t(43)=3.81, P=0.001. The internal consistency of the scale is high, the coefficient KR-20 being 0.86.

Reduced Awareness of Memory Deficit is Associated With Increased Medicare Home Health Care Use in Dementia

OBJECTIVE

The objective of this study was to examine whether reduced awareness of memory deficits in individuals with dementia is associated with more frequent need for Medicare home health care services.

METHODS

Cross-sectional analyses were conducted in a multicenter, clinic-based cohort. In total, 192 participants diagnosed with dementia and their informants were independently asked whether or not the participant demonstrated cognitive symptoms of dementia related to memory and word-finding. Participant self-awareness was measured as the discrepancy between participant and caregiver report of these symptoms. Annual Medicare home health benefit use data was obtained from Medicare claims matched by year to the Predictors study visit.

RESULTS

Participants that used home health services had lower awareness scores than those who did not. Awareness remained independently associated with home health use in a logistic regression adjusted for age, gender, education, caregiver relationship, global cognition, dementia subtype, and medical comorbidities.

IMPLICATIONS

Reduced self-awareness of memory deficits in individuals with dementia is associated with more frequent use of Medicare home health services. The disproportionate use of in-home assistance as a function of awareness level may reflect dangers faced by patients, and challenges faced by caregivers, when patients have limited awareness of their memory deficits. Current results have implications for clinical care, caregiver education, and models of health care utilization.

The Screening Utility and Ecological Validity of the Neuropsychological Assessment Battery Bill Payment Subtest in Older Adults with and without Dementia

Objective

The Neuropsychological Assessment Battery Bill Payment subtest has shown strong diagnostic accuracy in dementia due to Alzheimer’s disease (AD) versus non-AD. Its relationship to mild cognitive impairment (MCI) or all-cause dementia has not been fully examined nor has its ecological validity as a proxy of financial independence.

Method

We describe 270 women (63%) and men (age = 72 ± 8.39) who completed Bill Payment during outpatient neuropsychological evaluation. Seventy-one were cognitively normal (CN), 160 had MCI, and 39 had Dementia. Two hundred fourteen were independent in money management, 31 were assisted (had oversight/some help), and 25 were dependent (relied on others). Receiver operating characteristic (ROC) curves tested Bill Payment’s utility as a dementia screen. Kruskal–Wallis tests examined whether Bill Payment differed by levels of financial independence.

Results

At a cutoff of 17, Bill Payment had strong sensitivity (0.87) and specificity (0.80) for dementia versus CN cases. A cutoff of 15 distinguished dementia from MCI (Sn = 0.64, Sp = 0.85), whereas a cutoff of 16 distinguished dementia from functionally unimpaired cases (MCI + CN) with greater sensitivity and similar specificity (Sn = 0.74, Sp = 0.81). Sensitivity attenuated in MCI versus CN cases (Sn = 0.46, Sp = 0.83). Those who were independent in money management had higher scores than assisted and dependent cases (p ≤ 0.046). Assisted and dependent cases were no different (p &gt; 0.05).

Conclusions

Bill Payment is a valid screen of all-cause dementia. Lower Bill Payment scores may mark subtle functional decline beyond cognitive impairment alone. Specifically, results provide preliminary evidence of Bill Payment’s ecological validity as a measure related to financial independence. It may prove useful when impaired financial abilities are suspected but unreported.

Measuring awareness in people with dementia: protocol for a scoping review

BACKGROUND

People with dementia (PwD) vary in the degree of awareness they show about their situation, both generally concerning the diagnosis and more specifically around certain aspects or objects of awareness such as awareness of memory impairment, altered daily activities or social functioning. The extent of awareness or lack of awareness has consequences for well-being of PwD and carers, impacting on rates of hospital admission, institutionalization, mood, adjustment to diagnosis, outcomes from intervention and carer burden. An accurate estimation of a person's awareness could therefore be useful in a clinical setting to support PwD and their carers in making appropriate choices for health and care decisions, and could facilitate safe management by health care professionals, e.g. in an acute care setting. There is a range of different approaches to measuring awareness reported in the dementia research literature, with varying estimates of the frequency of lack of awareness, reflecting different methodologies and populations. The majority of the methods have been developed for research purposes and may not be suitable for clinical use. There are no recent scoping or systematic reviews of the available methods.

METHOD

We will conduct a scoping review of published studies that have assessed awareness in people with dementia of all types, and all degrees of severity. The systematic search will include the electronic databases PubMed, Embase, PsycInfo, CINAHL, Web of Science and Cochrane Library, using search terms for dementia ("dement*" or "Alzheimer*" or "Pick's disease") and "awareness", "unawareness", "anosognosia", "insight", "denial", "metacognit*" or "discrepanc*" identified from pilot searches. Findings will be mapped and described according to the method used, the setting and diagnosis and the object of awareness studied if specified. Validated measures will be identified.

DISCUSSION

This scoping review will provide an overview of the methods used to measure awareness in people with dementia, allowing comparison of the methods along with identification of validated measures. The methods or components will be appraised for potential clinical use, and gaps in research will be highlighted.

Interaction between memory impairment and depressive symptoms can exacerbate anosognosia: a comparison of Alzheimer's disease with mild cognitive impairment

OBJECTIVE

To investigate the effects of interactions between memory impairment, depressive symptoms, and anosognosia.

METHODS

Anosognosia for memory impairment was assessed in 118 patients with Alzheimer's disease (AD), 47 patients with mild cognitive impairment (MCI), and 17 non-diagnosed controls (NC) using a questionnaire and evaluation of the anosognosia score as the discrepancy between ratings of the patient and a relative. Demographic characteristics, such as the relationship of the patient with the relative and the activities of daily living (ADL) were evaluated. Memory impairment was evaluated with the Rivermead Behavioral Memory Test (RBMT), depressive symptoms were evaluated using the Geriatric Depression Scale (GDS) 15 items version.

RESULTS

In the MCI group, a stepwise multiple regression analysis showed an interaction between RBMT and GDS scores, and simple slope analysis indicated that scores for RBMT at low GDS (-1 standard deviation) were positively correlated with self-rated memory impairment. In the AD group, the relationship of the patient with the relative, ADL, and GDS and RBMT scores were associated with the anosognosia score.

CONCLUSION

Patients with MCI who have no depressive symptoms may be able to more accurately evaluate their memory impairment than those who have depressive symptoms and patients with AD. The evaluation by relatives, depressive symptoms or ADL of patients may distort evaluation of anosognosia for memory impairment in patients with AD or MCI. It seems necessary to include not only depression scale scores but also results of objective memory tests in the patients' medical information for the correct assessment of anosognosia.

An evaluation of community-based cognitive stimulation therapy: a pilot study with an Irish population of people with dementia

OBJECTIVES

Research shows that cognitive stimulation therapy (CST) improves cognitive function, quality of life, and well-being of people with mild-moderate dementia. Despite consistent evidence and recommendations, CST is not routinely available in Ireland post-diagnosis. The aim of the current research was to develop and evaluate community-based CST for people with mild-moderate dementia, run by the Alzheimer Society of Ireland across four pilot sites in Ireland.

METHODS

Participants with mild-moderate dementia attended once weekly CST sessions for 14 weeks. Baseline and post-intervention assessments were completed by CST participants, carers, and CST facilitators. Primary outcomes of interest for CST participants included quality of life (Quality of Life in Alzheimer Disease Scale), cognitive function (Montreal Cognitive Assessment), and subjective cognitive function (Memory Awareness Rating Scale-Functioning Subscale). Secondary outcomes included well-being, cognitive ability, satisfaction with cognitive performance, and engagement and confidence of CST participants; well-being of carers; and job satisfaction of facilitators. Post-intervention interviews supplemented quantitative analyses.

RESULTS

In total, 20 CST participants, 17 carers, and six CST facilitators completed evaluation assessments. Results showed that CST improved participants' satisfaction with cognitive performance (p=0.002), level of engagement (p=0.046), level of confidence (p=0.026). Improvements on subjective cognitive function just fell short of significance (p=0.055). Qualitative analysis of interview data identified consistent themes of cognitive and overall benefits of CST; and provided support for quantitative data.

CONCLUSIONS

Community-based CST positively impacted the lives of people with dementia and their families. This study supports prior recommendations that CST should be made routinely available to people with mild-moderate dementia, particularly in light of the lack of post-diagnostic interventions currently offered in Ireland.

Cross domain self-monitoring in anosognosia for memory loss in Alzheimer's disease

Anosognosia for memory loss is a common feature of Alzheimer's disease (AD). Recent theories have proposed that anosognosia, a disruption in awareness at a global level, may reflect specific deficits in self-monitoring, or local awareness. Though anosognosia for memory loss has been shown to relate to memory self-monitoring, it is not clear if it relates to self-monitoring deficits in other domains (i.e., motor). The current study examined this question by analyzing the relationship between anosognosia for memory loss, memory monitoring, and motor monitoring in 35 individuals with mild to moderate AD. Anosognosia was assessed via clinical interview before participants completed a metamemory task to measure memory monitoring, and a computerized agency task to measure motor monitoring. Cognitive and psychological measures included memory, executive functions, and mood. Memory monitoring was associated with motor monitoring; however, anosognosia was associated only with memory monitoring, and not motor monitoring. Cognition and mood related differently to each measure of self-awareness. Results are interpreted within a hierarchical model of awareness in which local self-monitoring processes are associated across domain, but appear to only contribute to a global level awareness in a domain-specific fashion.

The Longitudinal Association Between a Discrepancy Measure of Anosognosia in Patients with Dementia, Caregiver Burden and Depression

BACKGROUND

According to cross-sectional studies, there is an association between anosognosia in people with dementia and caregiver's burden and depression. Anosognosia in patients may be a cause of caregiver burden and depression. However, variability in caregiver anosognosia ratings may exist as caregivers with burden and depression may have a more pessimistic view of the patients' health.

OBJECTIVE

To assess the variability of caregiver anosognosia ratings of patients with dementia using a widely used anosognosia scale and its longitudinal relationship with caregiver burden and depression.

METHODS

A convenience cohort of 221 consecutive dementia outpatient and caregiver dyads was followed up at 12 and 24 months. The main instruments used were the Anosognosia Questionnaire-Dementia (AQ-D), Caregiver Burden Interview, and Geriatric Depression Scale. Linear mixed models were used including time as a factor in every model. Multivariate analyses controlled for caregiver's socio-demographic and possible confounding factors.

RESULTS

Attrition at 12 and 24 months was 24.9% and 42.5% respectively. Patients at baseline were on average 77.8 years of age, 63.3% were women, and 63.3% had < 5 years of education. In the bivariate analyses, caregiver burden, depression, and gender were associated with caregiver ratings of total, cognitive, and personality AQ-D of the patient at different time points. Multivariate analyses revealed burden as the caregiver variable most consistently associated with total, cognitive, and personality caregiver AQ-D ratings of the patient.

CONCLUSION

Some caregiver characteristics, especially burden, are associated with caregiver ratings of AQ-D with regard to the patient.

Consequences of Anosognosia on the Cost of Caregivers' Care in Alzheimer's Disease

BACKGROUND

Anosognosia is common in patients with Alzheimer's disease (AD) and it is frequently related to an increase in time of care demand.

OBJECTIVE

The aim of the study was to examine the effect of anosognosia on the total costs of informal care in patients with AD.

METHODS

This was a prospective longitudinal study with community-dwelling AD patients. Anosognosia, time of informal care, and the use of support services (e.g., day care centers) were recorded at baseline and after 24 months. The cost of informal caregiving was calculated as 'market price'.

RESULTS

At baseline, the prevalence of anosognosia was 54.3% (n = 221), and 43.9% were classified as mild-AD. The average time of care was 5 h/day±2.4 (IADL: 1.3 h/day±1.4 and BADL: 3.6 h/day±1.5). Thirty percent of the patients used home care services, and 25.1% attended a day care center. Patients with anosognosia received more time of care and were more likely to use support services than did their no-anosognosia peers, including institutionalization. The mean cost of support services was 490.4€ /month (SD = 413.1€; range = 25-2,212.38€), while the overall cost of care (support services plus informal care) was 1,787€ /month (SD = 972.4€), ranging from 834.1€ in mild-AD without anosognosia patients, to 2,424.8€ in severe-AD with incident anosognosia patients.

CONCLUSIONS

Anosognosia was associated with an increased number of hours of informal care, and a greater use of support services, regardless of the severity of the dementia, which lead to an increase of the total family-care costs.

Awareness of functional ability in people with early-stage dementia

OBJECTIVES

Assessment of functional ability in people with early-stage dementia (PwD) is an important area of study because it forms part of the diagnostic process and may help in monitoring disease progression. Most researchers and clinicians rely on informant ratings rather than observing actual functional performance or employing self-ratings. There has however been little research to verify whether informant ratings of functioning are accurate, and there has been even less research investigating the accuracy of self-ratings of functional ability in PwD. No study has used the performance-monitoring metacognitive approach to investigate awareness of functional ability.

METHODS

Thirty-seven people with early-stage dementia completed an objective functional assessment and provided self-ratings before and after completing each section of the objective test. Informants provided ratings of functioning and burden. Scores were converted to percentages to allow for direct comparison.

RESULTS

Objectively assessed functional ability significantly correlated with self-ratings and informant ratings. Self-ratings did not correlate with informant ratings. For converted scores, self-ratings were more similar than informant ratings to the objectively assessed mean scores. Burden was unrelated to functional assessments after correcting for multiple comparisons.

CONCLUSIONS

Self-rated functional ability was more accurate than informant ratings when compared with objectively assessed ability, with informants tending to significantly underestimate the functional ability of PwD. The findings call into question the likelihood that informants will provide accurate ratings of functional ability and suggests that self-ratings may offer a more accurate estimate of functional ability. Self-ratings made by PwD should be more widely employed in clinical and research settings. Copyright © 2017 John Wiley & Sons, Ltd.

Are Disagreements in Caregiver and Patient Assessment of Patient Health Associated with Increased Caregiver Burden in Caregivers of Older Adults with Cancer?

BACKGROUND

As patients age, caregivers increasingly provide essential support and patient information. We sought to determine if patient-caregiver assessments of patient health differ and if differences contribute to burden in caregivers of older adults with cancer.

MATERIALS AND METHODS

One hundred patients, aged ≥65, and their caregivers independently assessed patient function, comorbidity, nutrition, social activity, social support, and mental health. Caregivers completed the Caregiver Strain Index (CSI). Patient-caregiver assessments were compared using the Wilcoxon signed rank test and paired t test. Association between caregiver burden and differences between patient-caregiver assessments was examined using generalized linear regression.

RESULTS

Median patient age was 70 (range 65-91) and 70% had advanced disease. Sixty percent of patients reported requiring help with instrumental activities of daily living (IADLs); most had good social support (median Medical Outcomes Study [MOS]-Social Support Survey score 92) and mental health (median Mental Health Inventory score 85).Caregivers were a median age of 66 (range 28-85), 73% female, 68% spousal caregivers, and 79% lived with the patient. Caregivers rated patients as having poorer physical function (more IADLs dependency [p = .008], lower Karnofsky Performance Status [p = .02], lower MOS-Physical Function [p < .0001]), poorer mental health (p = .0002), and having more social support (p = .03) than patients themselves. Three-quarters of caregivers experienced some caregiver burden (mean CSI score 3.1). Only differences in patient-caregiver assessment of the patient's need for help with IADLs were associated with increased caregiver burden (p = .03).

CONCLUSION

Patient-caregiver assessments of patient function, mental health, and social support differ. However, only differences in assessment of IADLs dependency were associated with increased caregiver burden.

IMPLICATIONS FOR PRACTICE

As patients age, there is a higher incidence of frailty and cognitive impairments. As a result, caregivers play an increasingly vital role in providing information about patient health to healthcare providers, which is used to help healthcare providers tailor treatments and optimize patient health. These findings highlight that caregiver reporting in older adults with cancer may not replace patient reporting in those older adults who are otherwise able to self-report. Furthermore, clinicians should check for caregiver burden in caregivers who report providing more help with instrumental activities of daily living than patients themselves report and provide appropriate support as needed.

Development of a Proxy-Free Objective Assessment Tool of Instrumental Activities of Daily Living in Mild Cognitive Impairment Using Smart Home Technologies

BACKGROUND

The assessment of activities of daily living (ADL) is essential for dementia diagnostics. Even in mild cognitive impairment (MCI), subtle deficits in instrumental ADL (IADL) may occur and signal a higher risk of conversion to dementia. Thus, sensitive and reliable ADL assessment tools are important. Smart homes equipped with sensor technology and video cameras may provide a proxy-free assessment tool for the detection of IADL deficits.

OBJECTIVE

The aim of this paper is to investigate the potential of a smart home environment for the assessment of IADL in MCI.

METHOD

The smart home consisted of a two-room flat equipped with activity sensors and video cameras. Participants with either MCI or healthy controls (HC) had to solve a standardized set of six tasks, e.g., meal preparation, telephone use, and finding objects in the flat.

RESULTS

MCI participants needed more time (1384 versus 938 seconds, p <  0.001) and scored less total points (48 versus 57 points, p <  0.001) while solving the tasks than HC. Analyzing the subtasks, intergroup differences were observed for making a phone call, operating the television, and retrieving objects. MCI participants showed more searching and task-irrelevant behavior than HC. Task performance was correlated with cognitive status and IADL questionnaires but not with participants' age.

CONCLUSION

This pilot study showed that smart home technologies offer the chance for an objective and ecologically valid assessment of IADL. It can be analyzed not only whether a task is successfully completed but also how it is completed. Future studies should concentrate on the development of automated detection of IADL deficits.

Predictors of well-being among significant others of persons with multiple sclerosis

Objective

To examine patient and significant other characteristics as predictors of significant other well-being.

Methods

A total of 74 persons with multiple sclerosis (MS) and their significant others participated. Executive functioning was measured using neuropsychological tests. Awareness of cognitive deficit was measured as the discrepancy between the patient's reports of their abilities and objective test results. Awareness of functional deficit was measured as the discrepancy between the patient's and significant other's reports of the patient's functional abilities. Patient neurobehavioral disturbance was measured using a significant-other rated questionnaire. Significant other perceived social support and well-being (ie, psychological distress, life satisfaction, and general health status) were assessed using questionnaires filled out by the significant other.

Results

Executive dysfunction, neurobehavioral disturbance, and lack of awareness of functional deficits in patients were associated with poor well-being outcomes; whereas, lack of awareness of cognitive deficits was only weakly related to well-being. Social support was associated with positive well-being outcomes.

Conclusions

Diminished insight regarding functional limitations may increase significant others’ supervisory burden as patients attempt activities independently, whereas lack of awareness of cognitive deficits may not be directly associated with behavior-relevant impairments that significant others find distressing. Social support appears to be a powerful aid in diffusing the distress among significant others of MS patients. Multiple Sclerosis 2007; 13: 238–249. http://msj.sagepub.com

Heterogeneity of Cognitive Anosognosia and its Variation with the Severity of Dementia in Patients with Alzheimer's Disease

Currently, the lack of awareness of deficits, i.e., anosognosia, is a major obstacle in the healthcare circuit that delays the diagnosis of Alzheimer's disease (AD). However, a clear framework is lacking in the literature related to this phenomenon in terms of its definition, mechanisms, and objects. The aim of this study is to assess the different levels of cognitive anosognosia using a prediction-performance procedure and to identify the potential correlates of these levels. A sample of patients with probable AD was divided into three groups according to the severity of dementia (mild (MiD), moderate (MoD), and moderately severe (MSD) dementia), ranked according to the results of the Mini-Mental State Examination. We observed the following three scores: the real score, the prediction score, and the anosognosia score. These scores were calculated based on the prediction-performance task MISAwareness from the Dementia Rating Scale for cognitive processes (i.e., Attention, Initiation, Conceptualization, Construction, and Memory). We obtained a strong plateau effect between the MiD and MoD groups for anosognosia scores for actual performance or prediction for both the level of overall functioning and for specific processes. The sole exception was the result for memory processes. Moreover, the profiles of the patients' responses on the Memory subscale were substantially different and, indeed, opposite from those for the other processes. The main results confirm the multidimensionality of anosognosia and its variability with the stage of dementia and specifically implicate memory processes that indicate a cleavage between memory and other cognitive functions.

Staff helping behaviors: Alzheimer day care

Helping behaviors of staff members at an Alzheimer day care center were examined through participant observation and ethnographic interviewing. Analysis of the field notes and interview data revealed a primary theme of prevention of harm in the helping patterns and secondary themes of enhancing client function and providing social connectedness. Comparisons with relational and dependency models of helping are made and implications for dementia care are discussed.

Grief and Mourning from the Perspective of the Person with a Dementing Illness: Beginning the Dialogue

While working with individuals with Alzheimer's disease and other dementing disorders presents many challenges for clinicians, none is more difficult than watching an individual who is cognitively impaired mourn the losses of life and those imposed by the dementing illness. There now is a body of literature on grief in caregivers, but little has been written to help clinicians understand or better support affected individuals who are experiencing multiple losses and yet whose insight, autobiographical memory, and connectedness to others is beginning to blur and fade. This article addresses current models of grief, examines the ability or inability of affected individuals to experience and resolve grief, and attempts to formulate questions that may ultimately allow clinicians and caregivers to better recognize and address the difficult issues of the grief response and mourning process in the person with dementing illness.

Negotiating the Impact of Forgetting

Dialectical and social constructionist approaches to dementia emphasize the importance of social interaction, and recent work has begun to call for a more relationship-based approach. However, little attention has yet been paid to the interactions of couples where one partner has early-stage dementia. This article describes some of the findings from an exploratory, qualitative study investigating conversational interactions between people with early-stage dementia and their spouses. Analysis of data from ten couples draws primarily on voice-relational analytic methods to explore how these couples use talk in conversation to negotiate and co-construct an account of their situation, and to outline the dimensions of resistance in this context. The findings suggest a need to attend to interaction and conversation from the very earliest stages of dementia. The concept of resistance, as evidenced in the interactions presented here, provides a framework that can assist in this endeavour.

Quality of Life and Deficit Identification in Dementia

Numerous studies have examined self-identification of deficits in persons with dementia. Few of these studies consider the influence of interpersonal and social factors on deficit identification, and most focus on whether or why deficits are ‘underreported’ by persons with dementia. In our studies, we found considerable variation in deficit identification within and among persons with dementia, and some ‘overreporting’ of deficits in comparison with caregiver reports across all of the domains studied. Thus, focusing on ‘underreporting’ and aggregate level data neglects information that could be important to measuring and understanding quality of life in dementia. Current approaches to measuring and understanding quality of life in dementia make divergent assumptions about the impact of deficit identification. Emerging phenomenological perspectives suggest that proactive interventions that treat deficit identification as an interpersonal and social challenge inherent in the experience of dementia would enhance the quality of life of caregiving dyads.

Striving for connection

A number of models have been proposed to describe the processes of appraisal and coping in early-stage dementia, but possible gender differences remain to be explored. The present study focused specifically on women with early-stage Alzheimer's disease, and examined how they made sense of, and attempted to cope with, their situation. Transcripts of interviews with nine women were analysed using Interpretative Phenomenological Analysis. Ten key themes were identified, which were grouped into three higher-order themes: connectedness, protective strategies and adjustment. The women experienced memory problems as a threat to the sense of connectedness they derived from attachment to family and friends, affiliation with social roles and familiarity with their surroundings. A Level of Connectedness Model of the appraisal and coping processes of women with early-stage Alzheimer's disease is presented, which places coping in an interpersonal framework, whereby a woman's ability to maintain a sense of self is inherently dependent on the readiness of others to facilitate connectedness. This provides a focus for possible further development of psychosocial interventions that consider well-being in an interpersonal context.

The Apathy Evaluation Scale: A Comparison of Subject, Informant, and Clinician Report in Cognitively Normal Elderly and Mild Cognitive Impairment

BACKGROUND

Apathy is a common neuropsychiatric symptom in Alzheimer's disease (AD) dementia and mild cognitive impairment (MCI). Detecting apathy accurately may facilitate earlier diagnosis of AD. The Apathy Evaluation Scale (AES) is a promising tool for measurement of apathy in prodromal and possibly preclinical AD.

OBJECTIVE

To compare the three AES sub-scales - subject-reported (AES-S), informant-reported (AES-I), and clinician-reported (AES-C) - over time in individuals at risk for AD due to MCI and advanced age (cognitively normal [CN] elderly).

METHODS

Mixed effects longitudinal models were used to assess predictors of score for each AES sub-scale. Cox proportional hazards models were used to assess which AES sub-scales predict progression from MCI to AD dementia.

RESULTS

Fifty-seven MCI and 18 CN subjects (ages 53-86) were followed for 1.4 ± 1.2 years and 0.7 ± 0.7 years, respectively. Across the three mixed effects longitudinal models, the common findings were associations between greater apathy and greater years in study, a baseline diagnosis of MCI (compared to CN), and male gender. CN elderly self-reported greater apathy compared to that reported by informants and clinicians, while individuals with MCI under-reported their apathy compared to informants and clinicians. Of the three sub-scales, the AES-C best predicted transition from MCI to AD dementia.

CONCLUSION

In a sample of CN elderly and elderly with MCI, apathy increased over time, particularly in men and those with MCI. AES-S scores may be more sensitive than AES-I and AES-C scores in CN elderly, but less reliable if subjects have MCI. Moreover, the AES-C sub-scale predicted progression from MCI to AD dementia.

Possible selves and illness: A comparison of individuals with Parkinson's disease, early-stage Alzheimer's disease, and healthy older adults

This study examined how future self-representations are affected by two different chronic illnesses, one focused on cognitive losses, early-stage Alzheimer's disease (AD), and one focused on physical losses, Parkinson's disease (PD). The impact of illness on possible selves (perceptions of self in the future) was made salient by a comparison with healthy older adults in order to better understand developmental issues in later life. Findings show that although there were no differences in the total number of domains reported by the groups, specific domains were reported differently by patient groups and all domains were likely to become infused with illness. As expected, patient groups had less self-efficacy and lower outcome expectancies for their future selves, and PD patients reported less distance from their feared selves. Although these findings are intuitive, this is the first empirical effort to document the impact of illness on older adults' self-representations. Group differences are explained in terms of disease context, and the importance of possible selves and self-regulatory functions as therapeutic mechanisms for adaptation to illness are emphasised.

Awareness Deficits in Alzheimer's Disease: Issues in Assessment and Intervention

Unawareness of deficits is a challenging problem frequently encountered in individuals with Alzheimer's disease (AD). Understanding mediating and causative factors of unawareness is important for accurate assessment and effective intervention. However, clinicians should also consider the variability that is often present between and within AD patients and should avoid the use of dichotomous classifications of unawareness. In this article, current knowledge generated by both neurosciences and behavioral sciences provides the basis for identifying issues and offering recommendations pertinent to assessment and intervention of awareness deficits m AD. Remedial and compensatory efforts used with head-injured patients may have potential application to dementia patients with awareness deficits, especially for those in earlier stages. Knowledge in this area is still in an early stage of investigation. As more is known about the nature of awareness deficits, it will be possible to design more effective approaches based on the characteristics of individual patients.

Screening for Frailty in Canada's Health Care System: A Time for Action

As Canada's population ages, frailty - with its increased risk of functional decline, deterioration in health status, and death - will become increasingly common. The physiology of frailty reflects its multisystem, multi-organ origins. About a quarter of Canadians over age 65 are frail, increasing to over half in those older than 85. Our health care system is organized around single-organ systems, impairing our ability to effectively treat people having multiple disorders and functional limitations. To address frailty, we must recognize when it occurs, increase awareness of its significance, develop holistic models of care, and generate better evidence for its treatment. Recognizing how frailty impacts lifespan will allow for integration of care goals into treatment options. Different settings in the Canadian health care system will require different strategies and tools to assess frailty. Given the magnitude of challenges frailty poses for the health care system as currently organized, policy changes will be essential.

Occupational Performance and Metacognition

This paper provides definitions of the concept of metacognition and explores its relationship to occupational performance. Metacognition is divided into two components: awareness and exec utive functions. Assessments of awareness and executive functions are reviewed, treatment guidelines for metacognitive deficits are delineated, and research findings related to clients with neurological dysfunctions are summarized. Finally, the importance of integrating metacognitive components into occupational therapy theory and practice is emphasized.

[Geriatric psychiatric home counseling for people with dementia and anosognosia : Results of a model project]

BACKGROUND

Lack of awareness of an illness (anosognosia) is a common symptom in dementia and has a significant impact on the course of the disease. It is associated with dysfunctional interaction with caregivers. Due to unawareness patients are not able to accept diagnostic procedures or medical treatment and refuse any kind of support. Thus, they are not integrated into psychosocial networks and medical support. This has a significant impact on patient-centered care in a domestic environment. In this article a model project with home visits to patients with dementia and anosognosia is described.

METHOD

A total of 55 home visits were carried out. The aim of this project was the integration into the existing healthcare services in order to safeguard the domestic environment. These visits focused on advice and information for the patients and their caregivers initiating the visits. Sociodemographic data of the patient cohort and the satisfaction of the caregiving relatives and general practitioners are presented.

RESULTS

Subjects with dementia were found to be in advanced stages of the disease, caring situations were complex and required assistance. Caregivers showed a substantial burden in accordance with previous reports.

CONCLUSION

New strategies are required to cope with anosognosia in patients with dementia and their caregivers. Even single home visits seem to be sufficient to initiate support for subjects with dementia and their relatives.

Examining the Pathways Between Self-Awareness and Well-Being in Mild to Moderate Alzheimer Disease

OBJECTIVE

To investigate the relationship between awareness of memory loss and psychological well-being in a nonclinically depressed sample of participants with mild to moderate Alzheimer disease (AD).

METHODS

Study participants (N = 104) enrolled through Columbia University Medical Center and the University of Pennsylvania completed clinical and cognitive assessments. Participants were rated with regard to their degree of awareness of memory deficits and completed questionnaires relating to their psychological well-being, including mood and quality of life (QOL). Mediating models were used to establish the relationship between awareness, depression, and QOL and to examine potential mediators of awareness and depression, including psychological distress, objective memory deficits, and negative self-ratings.

RESULTS

There was a direct association between awareness of memory deficits and depressed mood but not awareness and QOL. However, there was an indirect association between awareness and QOL through depression. Neither psychological distress, memory deficits, nor negative self-ratings mediated the relationship between awareness and depression.

CONCLUSION

Awareness is associated with depressed mood in nonclinically depressed participants with mild to moderate AD. However, depressed mood does not appear to reflect the direct psychological reaction to awareness of memory loss. Moreover, awareness has only an indirect association with QOL via depressed mood. These results suggest that preserved awareness does not have a direct negative impact on overall psychological well-being in AD.

Ecological Assessment of Autonomy in Instrumental Activities of Daily Living in Dementia Patients by the Means of an Automatic Video Monitoring System

Currently, the assessment of autonomy and functional ability involves clinical rating scales. However, scales are often limited in their ability to provide objective and sensitive information. By contrast, information and communication technologies may overcome these limitations by capturing more fully functional as well as cognitive disturbances associated with Alzheimer disease (AD). We investigated the quantitative assessment of autonomy in dementia patients based not only on gait analysis but also on the participant performance on instrumental activities of daily living (IADL) automatically recognized by a video event monitoring system (EMS). Three groups of participants (healthy controls, mild cognitive impairment, and AD patients) had to carry out a standardized scenario consisting of physical tasks (single and dual task) and several IADL such as preparing a pillbox or making a phone call while being recorded. After, video sensor data were processed by an EMS that automatically extracts kinematic parameters of the participants’ gait and recognizes their carried out activities. These parameters were then used for the assessment of the participants’ performance levels, here referred as autonomy. Autonomy assessment was approached as classification task using artificial intelligence methods that takes as input the parameters extracted by the EMS, here referred as behavioral profile. Activities were accurately recognized by the EMS with high precision. The most accurately recognized activities were “prepare medication” with 93% and “using phone” with 89% precision. The diagnostic group classifier obtained a precision of 73.46% when combining the analyses of physical tasks with IADL. In a further analysis, the created autonomy group classifier which obtained a precision of 83.67% when combining physical tasks and IADL. Results suggest that it is possible to quantitatively assess IADL functioning supported by an EMS and that even based on the extracted data the groups could be classified with high accuracy. This means that the use of such technologies may provide clinicians with diagnostic relevant information to improve autonomy assessment in real time decreasing observer biases.