The diagnostic value of IADL evaluation in the detection of dementia in general practice

Adaptive Functioning Among Older Adults: The Essence of Information Processing Speed in Executive Functioning

OBJECTIVE

The current study investigated the degree to which information processing speed mediates the association between executive functioning and adaptive functioning among older adults.

METHOD

Cases (N = 239) were selected from a clinical database of neuropsychological evaluations. Inclusion criteria were age 60+ (M = 74.0, standard deviation = 6.9) and completion of relevant study measures. Participants were majority White (93%) women (53.1%). The Texas Functional Living Scale was used as a performance-based measure of adaptive functioning. Information processing speed was measured using the Coding subtest from the Repeatable Battery for the Assessment of Neuropsychological Status. Executive functioning performance was quantified using part B of the Trail Making Test, Controlled Oral Word Association Test, and Similarities and Matrix Reasoning subtests from the Wechsler Abbreviated Scale of Intelligence, second edition. Mediation models were assessed with bootstrapped confidence intervals.

RESULTS

Information processing speed mediated all measures of executive functioning. Direct effects were significant for all models (ps < 0.03), suggesting that executive functioning maintained unique associations with adaptive functioning. Follow-up analyses indicated no evidence for moderation of the mediation models based on diagnostic group. Additional models with executive functioning mediating information processing speed and adaptive functioning revealed inconsistent mediation, with smaller effects.

CONCLUSIONS

Results highlight the importance of information processing speed in understanding real-world implications of pathological and non-pathological cognitive aging. Information processing speed mediated all relationships between executive functioning and adaptive functioning. Further investigation is warranted into the importance of processing speed in explaining associations of other cognitive domains with adaptive functioning.

Associations between social determinants of health and 10-year change in everyday functioning within Black/African American and White older adults enrolled in ACTIVE

Introduction

Given prior work showing racial differences on baseline social determinants of health (SDoH) and 10-year trajectories of everyday functioning, we examined associations between SDoH and longitudinal everyday functioning performance in Black/African American and White older adults.

Methods

Participants were 2505 older adults (M_age = 73.5; 28% Black/African American) without dementia. SDoH included economic stability/status, education access/quality, health-care access, neighborhood/built environment, and social/community contexts. The Observed Tasks of Daily Living (OTDL) measured everyday functioning and was administered at baseline and 1-, 2-, 3-, 5-, and 10-year visits.

Results

Across the sample, social and community context and economic stability/status were associated with steeper age-related OTDL declines (βs = 0.05 to 0.07, Ps < 0.001). Lower levels of social and community context (β = 0.08, P = 0.002) and economic stability/status (β = 0.07, P = 0.04) were associated with OTDL linear age declines in Black/African American participants, but not in White participants (Ps > 0.30).

Discussion

Inequities across SDoH accelerate age-related declines in everyday functioning among Black/African American older adults.

Clinical judgement by primary care physicians for the diagnosis of all-cause dementia or cognitive impairment in symptomatic people

BACKGROUND

In primary care, general practitioners (GPs) unavoidably reach a clinical judgement about a patient as part of their encounter with patients, and so clinical judgement can be an important part of the diagnostic evaluation. Typically clinical decision making about what to do next for a patient incorporates clinical judgement about the diagnosis with severity of symptoms and patient factors, such as their ideas and expectations for treatment. When evaluating patients for dementia, many GPs report using their own judgement to evaluate cognition, using information that is immediately available at the point of care, to decide whether someone has or does not have dementia, rather than more formal tests.

OBJECTIVES

To determine the diagnostic accuracy of GPs' clinical judgement for diagnosing cognitive impairment and dementia in symptomatic people presenting to primary care. To investigate the heterogeneity of test accuracy in the included studies.

SEARCH METHODS

We searched MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), Web of Science Core Collection (ISI Web of Science), and LILACs (BIREME) on 16 September 2021.

SELECTION CRITERIA

We selected cross-sectional and cohort studies from primary care where clinical judgement was determined by a GP either prospectively (after consulting with a patient who has presented to a specific encounter with the doctor) or retrospectively (based on knowledge of the patient and review of the medical notes, but not relating to a specific encounter with the patient). The target conditions were dementia and cognitive impairment (mild cognitive impairment and dementia) and we included studies with any appropriate reference standard such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), aetiological definitions, or expert clinical diagnosis.

DATA COLLECTION AND ANALYSIS

Two review authors screened titles and abstracts for relevant articles and extracted data separately with differences resolved by consensus discussion. We used QUADAS-2 to evaluate the risk of bias and concerns about applicability in each study using anchoring statements. We performed meta-analysis using the bivariate method.

MAIN RESULTS

We identified 18,202 potentially relevant articles, of which 12,427 remained after de-duplication. We assessed 57 full-text articles and extracted data on 11 studies (17 papers), of which 10 studies had quantitative data. We included eight studies in the meta-analysis for the target condition dementia and four studies for the target condition cognitive impairment. Most studies were at low risk of bias as assessed with the QUADAS-2 tool, except for the flow and timing domain where four studies were at high risk of bias, and the reference standard domain where two studies were at high risk of bias. Most studies had low concern about applicability to the review question in all QUADAS-2 domains. Average age ranged from 73 years to 83 years (weighted average 77 years). The percentage of female participants in studies ranged from 47% to 100%. The percentage of people with a final diagnosis of dementia was between 2% and 56% across studies (a weighted average of 21%). For the target condition dementia, in individual studies sensitivity ranged from 34% to 91% and specificity ranged from 58% to 99%. In the meta-analysis for dementia as the target condition, in eight studies in which a total of 826 of 2790 participants had dementia, the summary diagnostic accuracy of clinical judgement of general practitioners was sensitivity 58% (95% confidence interval (CI) 43% to 72%), specificity 89% (95% CI 79% to 95%), positive likelihood ratio 5.3 (95% CI 2.4 to 8.2), and negative likelihood ratio 0.47 (95% CI 0.33 to 0.61). For the target condition cognitive impairment, in individual studies sensitivity ranged from 58% to 97% and specificity ranged from 40% to 88%. The summary diagnostic accuracy of clinical judgement of general practitioners in four studies in which a total of 594 of 1497 participants had cognitive impairment was sensitivity 84% (95% CI 60% to 95%), specificity 73% (95% CI 50% to 88%), positive likelihood ratio 3.1 (95% CI 1.4 to 4.7), and negative likelihood ratio 0.23 (95% CI 0.06 to 0.40). It was impossible to draw firm conclusions in the analysis of heterogeneity because there were small numbers of studies. For specificity we found the data were compatible with studies that used ICD-10, or applied retrospective judgement, had higher reported specificity compared to studies with DSM definitions or using prospective judgement. In contrast for sensitivity, we found studies that used a prospective index test may have had higher sensitivity than studies that used a retrospective index test.

AUTHORS' CONCLUSIONS

Clinical judgement of GPs is more specific than sensitive for the diagnosis of dementia. It would be necessary to use additional tests to confirm the diagnosis for either target condition, or to confirm the absence of the target conditions, but clinical judgement may inform the choice of further testing. Many people who a GP judges as having dementia will have the condition. People with false negative diagnoses are likely to have less severe disease and some could be identified by using more formal testing in people who GPs judge as not having dementia. Some false positives may require similar practical support to those with dementia, but some - such as some people with depression - may suffer delayed intervention for an alternative treatable pathology.

Family-Centered Primary Care for Older Adults with Cognitive Impairment

Cognitive impairment (e.g. dementia) presents challenges for individuals, their families, and healthcare professionals alike. The primary care setting presents a unique opportunity to care for older adults living with cognitive impairment, who present with complex care needs that may benefit from a family-centered approach. This indepth systematic review was completed to address three aims: (a) identify the ways in which families of older-adult patients with cognitive impairment are engaged in primary care settings, (b) examine the outcomes of family engagement practices, and (c) organize and discuss the findings using CJ Peek's Three World View. Researchers searched PubMed, Embase, and PsycINFO databases through July 2019. The results included 22 articles out of 6743 identified in the initial search. Researchers provided a description of the emerging themes for each of the three aims. It revealed that family-centered care and family engagement yields promising results including improved health outcomes, quality care, patient experience, and caregiver satisfaction. Furthermore, it promotes and advances the core values of medical family therapy: agency and communion. This review also exposed the inconsistent application of family-centered practices and the need for improved interprofessional education of primary care providers to prepare multidisciplinary teams to deliver family-centered care. Utilizing the vision of Patient- and Family-Centered Care and the lens of the Three World View, this systematic review provides Medical Family Therapists, healthcare administrators, policy makers, educators, and clinicians with information related to family engagement and how it can be implemented and enhanced in the care of patients with cognitive impairment.

Clinical judgment of GPs for the diagnosis of dementia: a diagnostic test accuracy study

BACKGROUND

GPs often report using clinical judgment to diagnose dementia.

AIM

To investigate the accuracy of GPs' clinical judgment for the diagnosis of dementia.

DESIGN & SETTING

Diagnostic test accuracy study, recruiting from 21 practices around Bristol, UK.

METHOD

The clinical judgment of the treating GP (index test) was based on the information immediately available at their initial consultation with a person aged ≥70 years who had cognitive symptoms. The reference standard was an assessment by a specialist clinician, based on a standardised clinical examination and made according to the 10th revision of the International Classification of Diseases (ICD-10) criteria for dementia.

RESULTS

A total of 240 people were recruited, with a median age of 80 years (interquartile range [IQR] 75-84 years), of whom 126 (53%) were men and 132 (55%) had dementia. The median duration of symptoms was 24 months (IQR 12-36 months) and the median Addenbrooke's Cognitive Examination III (ACE-III) score was 75 (IQR 65-87). GP clinical judgment had sensitivity 56% (95% confidence interval [CI] = 47% to 65%) and specificity 89% (95% CI = 81% to 94%). Positive likelihood ratio was higher in people aged 70-79 years (6.5, 95% CI = 2.9 to 15) compared with people aged ≥80 years (3.6, 95% CI = 1.7 to 7.6), and in women (10.4, 95% CI = 3.4 to 31.7) compared with men (3.2, 95% CI = 1.7 to 6.2), whereas the negative likelihood ratio was similar in all groups.

CONCLUSION

A GP clinical judgment of dementia is specific, but confirmatory testing is needed to exclude dementia in symptomatic people whom GPs judge as not having dementia.

Health status risk factors and quality of life in 75-84-year-old individuals assessed for dementia using the short 10/66 dementia diagnostic schedule

BACKGROUND

Trinidad is an island that not only has a population at high vascular risk but also one that is in epidemiological transition with high dementia prevalence. The aim of the study was to investigate modifiable risk factors associated with dementia in middle-old (75-84 years) individuals.

METHODS

As part of a large national community survey of dementia prevalence in Trinidad, 811 people aged 75-84 years were evaluated for dementia using the 10/66 short algorithm. Demographic data collected included information on age, gender, ethnicity, religion, education, occupation, living accommodation, smoking, alcohol consumption, self-reported medical conditions, impairments and ability to do instrumental activities of daily living (IADL). Data were analysed using multivariable logistic regression models.

RESULTS

Of the 811 participants, nearly 55% were female. The mean age was 78.8 (SD = 2.8) years and dementia was present in 198 (24.4%). Having less than ten years of education, being an agricultural worker, skilled labourer or housewife and having more than four co-morbidities were significantly associated with dementia. The odds ratio for dementia for those having self-reported stroke was 4.93 (95% CI [2.64-9.23]) and for diabetes was 1.76 (95% CI [1.17-2.65]) adjusting for age, age2, gender, ethnicity, religion, education and occupation. Impairment in eyesight, hearing, climbing stairs, and walking were also more common in the group with dementia. Ability to perform IADLs was linked with dementia. Individuals with dementia were more likely to be unable to perform any of the eight IADLs. Those who did not exercise at all (OR 6.95, 95% CI [2.02-23.90]) and those who did low exercise (OR 1.83, 95% CI [1.07-3.13]) compared to those who did moderate to high exercise were also more likely to have dementia.

CONCLUSION

In the middle-old population in Trinidad having diabetes and stroke, low IADL score, and no exercise were more common in people with dementia.

Relationship between executive dysfunction and neuropsychiatric symptoms and impaired instrumental activities of daily living among patients with very mild Alzheimer's disease

OBJECTIVES

Patients with Alzheimer's disease (AD) experience a gradual loss in their ability to perform instrumental activities of daily living (IADLs) from the early stage. A better understanding of the possible factors associated with IADL decline is important for the development of effective rehabilitation and support programs for patients with AD. Thus, we examined the relationships between comprehensive cognitive functions and neuropsychiatric symptoms and IADLs in patients with very mild AD.

METHODS

In total, 230 outpatients with probable AD were recruited from the Memory Clinic at Kumamoto University Hospital between May 2007 and October 2016. All patients scored ≥21 points on the Mini-Mental State Examination at the first assessment. Relationships between the subdomains of the Lawton IADL scale and neuropsychological/neuropsychiatric tests were examined by multiple regression analysis. All analyses were performed separately in men and women.

RESULTS

In female patients, scores on the Frontal Assessment Battery were significantly associated with telephone use ability, shopping, and ability to handle finances. Apathy scores in the Neuropsychiatric Inventory (NPI) were associated with telephone use ability, housekeeping, responsibility for own medications, and ability to handle finances. NPI agitation scores were associated with food preparation and housekeeping. Geriatric Depression Scale scores were associated with telephone use ability and ability to handle finances. In male patients, only NPI apathy scores were associated with telephone use ability.

CONCLUSIONS

These results suggest the importance of properly assessing executive function, depression, and apathy at interventions for impaired IADLs among female patients with very mild AD.

Daily functioning and dementia

Dementia is characterized by a decline in memory, language, problem-solving and in other cognitive domains that affect a person's ability to perform everyday activities and social functioning. It is consistently agreed that cognitive impairment is an important risk factor for developing functional disabilities in patients with dementia. Functional status can be conceptualized as the ability to perform self-care, self- maintenance and physical activity. A person with dementia usually requires help with more complex tasks, such as managing bills and finances, or simply maintaining a household. Good functional performance is fundamental for elderly people to maintain independency and avoid institutionalization. The purpose of this review is to describe functional changes in demented patients, evaluating the variability in subgroups of dementias.

The power of the Functional Activities Questionnaire for screening dementia in rural-dwelling older adults at high-risk of cognitive impairment

AIM

A simple approach to detecting dementia in its early stages may help improve patient care. We therefore aimed to assess the power of the Functional Activities Questionnaire (FAQ) for screening dementia among rural-dwelling older adults who are at high-risk for cognitive impairment.

METHODS

This study included 961 participants at a high-risk for dementia who had been identified from a population-based survey of Chinese rural residents. All participants were aged 65 years and older and positive for cognitive impairment according to the Mini-Mental State Examination or the Ascertain Dementia 8-item Informant Questionnaire screening tests. The FAQ scale was used to evaluate daily activities. Dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria. Receiver operating characteristic curve analyses were used to determine the FAQ's optimal cut-offs for dementia. The power (or accuracy) of the FAQ for screening dementia was analyzed in the total sample and in subgroups categorized by age, gender, and educational level.

RESULTS

Of the 961 participants, 84 (8.7%) were clinically diagnosed with dementia. Among individuals who were positive for cognitive impairment on the Mini-Mental State Examination or the Ascertain Dementia 8-item Informant Questionnaire, the parameters for an FAQ cut-off score ≥6 as a means of discriminating those with dementia from those without dementia were area under curve = 0.899, sensitivity = 94.1%, specificity = 75.1%, positive likelihood ratio = 3.78, and accuracy = 0.768. The discriminant abilities of the FAQ scale varied with age, gender, and educational level. The discriminant parameters of the FAQ scale were similar overall among individuals who were positive on either the Mini-Mental State Examination or the Ascertain Dementia 8-item Informant Questionnaire test alone.

CONCLUSION

The FAQ scale has high discriminative power to screen for dementia among rural older residents with suspected cognitive impairment.

How do impairments in cognitive functions affect activities of daily living functions in older adults?

The assessment of daily living activities could provide information about daily functions and participation restrictions to develop intervention strategies. The purposes of this study were to assess the scores of the Barthel Index (BI) and Lawton Instrumental Activities of Daily Living (IADL) scale in older adults with cognitive impairment and to explore the different effects that levels of cognitive functions have on changes in IADL functions. We recruited 31 participants with dementia, 36 with mild cognitive impairment (MCI), and 35 normal controls (NCs) from the neurology outpatient department of a regional hospital. The results of the demographic and clinical characteristics through the Lawton IADL scale, BI, Quick Mild Cognitive Impairment (Qmci) screen, Montreal Cognitive Assessment (MoCA), and Mini-Mental State Examination (MMSE), were collected on the same day and compared with the Kruskal-Wallis test, Wilcoxon rank-sum test, Fisher's exact test, and a multiple linear regression analysis, as appropriate. In the BI, bathing was the most discriminating activity to differentiate patients with MCI and dementia; in the Lawton IADL scale, medication responsibility and shopping were the most discriminating activities to differentiate NCs and patients with MCI, and patients with MCI and dementia, respectively. In addition, the predictors of changes in Lawton IADL scale scores were the problem-solving score of the Clinical Dementia Rating scale, a Qmci score of > 20.4 and an age of ≤ 81.2 years, a MoCA score of < 9.4 and an age of > 81.2 years, and the MMSE score and an age of > 81.2 years. This study adds to the evidence that the description of basic and instrumental daily activities is integrated in older adults with cognitive impairment. Notably, the Qmci is the most significant predictor of changes in IADL function for "young" older adults, as are the MoCA and MMSE for "old" older adults.

Diagnostic accuracy of Instrumental Activities of Daily Living for dementia in community-dwelling older adults

BACKGROUND

many people living with dementia remain underdiagnosed and unrecognised. Screening strategies are important for early detection.

OBJECTIVE

to examine whether the Lawton's Instrumental Activities of Daily Living (IADL) scale, compared with other cognitive screening tools-the Mini-Mental State Examination (MMSE), and the Ascertain Dementia 8-item Informant Questionnaire (AD8)-can identify older (≥ 65 years) adults with dementia.

DESIGN

population-based cross-sectional observational study.

SETTING

all 19 counties in Taiwan.

PARTICIPANTS

community-dwelling older adults (n = 10,340; mean age 74.87 ± 6.03).

METHODS

all participants underwent a structured in-person interview. Dementia was identified using National Institute on Aging-Alzheimer's Association core clinical criteria for all-cause dementia. Receiver operator characteristic curves were used to determine the discriminant abilities of the IADL scale, MMSE and AD8 to differentiate participants with and without dementia.

RESULTS

we identified 917 (8.9%) participants with dementia, and 9,423 (91.1%) participants without. The discriminant abilities of the MMSE, AD8 and IADL scale (cutoff score: 6/7; area under curve = 0.925; sensitivity = 89%; specificity = 81%; positive likelihood ratio = 4.75; accuracy = 0.82) were comparable. Combining IADL with AD8 scores significantly improved overall accuracy: specificity = 93%; positive likelihood ratio = 11.74; accuracy = 0.92.

CONCLUSIONS

our findings support using IADL scale to screen older community-dwelling residents for dementia: it has discriminant power comparable to that of the AD8 and MMSE. Combining the IADL and the AD8 improves specificity.

Living Alone With Cognitive Impairment

Although most individuals experiencing cognitive impairment (CI) reside with a caregiver, an estimated 800,000 live alone. Such individuals may have an increased risk for injury to self or others through self-neglect as a result of the CI symptoms. While persons living alone with CI have been identified as an important area for needed research, few studies have been able to examine this population due to the challenges of identifying and recruiting study participants. By using the National Health & Aging Trends Study data set, the researchers explored the characteristics to describe this population. The results of this study indicated that the majority of persons living with CI were older, widowed females who were not diagnosed with Alzheimer's or dementia but tested positive on cognitive screening measures. Further, the majority of persons living alone with CI relied on adult children and paid professionals as the primary care providers.

Adherence to Medication Regimens is an Effective Indicator of Cognitive Dysfunction in Elderly Individuals

BACKGROUND

Cognitive abilities strongly influence medication adherence among elderly individuals. We aimed to evaluate the relationship between medication adherence and cognitive decline using Lawton's instrumental activities of daily living (IADL) scoring system and the Mini-Mental State Examination (MMSE).

METHODS

Receiver-operating characteristic (ROC) curves were used to evaluate the IADL scores and MMSE results.

RESULTS

The ROC curve analysis of the IADL and MMSE results revealed that the shopping (MMSE cutoff = 22 points, sensitivity = 0.726, and specificity = 0.683) and responsibility for own medications (MMSE cutoff = 22 points, sensitivity = 0.759, and specificity = 0.720) categories were associated with declining IADL scores during early stage cognitive dysfunction.

CONCLUSION

Declining IADL scores in the shopping and responsibility for own medications categories may be effective indices for predicting early-stage cognitive dysfunction in elderly individuals. Cognitive dysfunction screening at pharmacy counters may be useful.

Brain morphology links systemic inflammation to cognitive function in midlife adults

BACKGROUND

Inflammation is linked to cognitive decline in midlife, but the neural basis for this link is unclear. One possibility is that inflammation associates with adverse changes in brain morphology, which accelerates cognitive aging and later dementia risk. Clear evidence is lacking, however, regarding whether inflammation relates to cognition in midlife via changes in brain morphology. Accordingly, the current study examines whether associations of inflammation with cognitive function are mediated by variation in cortical gray matter volume among midlife adults.

METHODS

Plasma levels of interleukin (IL)-6 and C-reactive protein (CRP), relatively stable markers of peripheral systemic inflammation, were assessed in 408 community volunteers aged 30-54 years. All participants underwent structural neuroimaging to assess global and regional brain morphology and completed neuropsychological tests sensitive to early changes in cognitive function. Measurements of brain morphology (regional tissue volumes and cortical thickness and surface area) were derived using Freesurfer.

RESULTS

Higher peripheral inflammation was associated with poorer spatial reasoning, short term memory, verbal proficiency, learning and memory, and executive function, as well as lower cortical gray and white matter volumes, hippocampal volume and cortical surface area. Mediation models with age, sex and intracranial volume as covariates showed cortical gray matter volume to partially mediate the association of inflammation with cognitive performance. Exploratory analyses of body mass suggested that adiposity may be a source of the inflammation linking brain morphology to cognition.

CONCLUSIONS

Inflammation and adiposity might relate to cognitive decline via influences on brain morphology.

A qualitative review of instrumental activities of daily living in dementia: what's cooking?

SUMMARY 

The measurement of instrumental activities of daily living (IADL) is common in clinical practice and research into dementia. IADL are cognitively complex daily activities, such as cooking and doing finances. Their measurement is required for the diagnostic process of dementia, and also useful for the monitoring of disease progression. Since problems in IADL contribute to the disease burden of both patient and caregiver, it is a relevant outcome measure for disease-modifying and non-pharmacological interventions. Despite the widespread use of IADL instruments, an overview of its theoretical background, measurement methods, and potential sources of bias is lacking. In the current manuscript, we therefore aim to provide a selective overview of these topics.

Assessment of instrumental activities of daily living in dementia: diagnostic value of the Amsterdam Instrumental Activities of Daily Living Questionnaire

BACKGROUND

Measuring impairments in "instrumental activities of daily living" (IADL) is important in dementia, but challenging due to the lack of reliable and valid instruments. We recently developed the Amsterdam Instrumental Activities of Daily Living Questionnaire (A-IADL-Q; note 1). We aim to investigate the diagnostic accuracy of the A-IADL-Q for dementia in a memory clinic setting.

METHODS

Patients visiting the Alzheimer Center of the VU University Medical Center with their informants between 2009 and 2011 were included (N = 278). Diagnoses were established in a multidisciplinary consensus meeting, independent of the A-IADL-Q scores. An optimal A-IADL-Q cutoff point was determined, and sensitivity and specificity were calculated. Area under the curves (AUCs) were compared between A-IADL-Q and "disability assessment of dementia" (DAD). The additional diagnostic value of the A-IADL-Q to Mini-Mental State Examination (MMSE) was examined using logistic regression analyses.

RESULTS

Dementia prevalence was 50.5%. Overall diagnostic accuracy based on the AUC was 0.75 (95% confidence interval [CI]: 0.70-0.81) for the A-IADL-Q and 0.70 (95% CI: 0.63-0.77) for the DAD, which did not differ significantly. The optimal cutoff score for the A-IADL-Q was 51.4, resulting in sensitivity of 0.74 and specificity of 0.64. Combining the A-IADL-Q with the MMSE improved specificity (0.94), with a decline in sensitivity (0.55). Logistic regression models showed that adding A-IADL-Q improved the diagnostic accuracy (Z = 2.55, P = .011), whereas the DAD did not.

CONCLUSIONS

In this study, we showed a fair diagnostic accuracy for A-IADL-Q and an additional value in the diagnosis of dementia. These results support the role of A-IADL-Q as a valuable diagnostic tool.

Examining the construct validity of the Cognitive Competency Test for occupational therapy practice / Évaluer la validité de construit du Cognitive Competency Test en fonction de la pratique de l’ergothérapie

Background.

Enhancing occupational therapy practice requires critical examination of assessment tools and the conclusions being drawn from their use. When working with cognitively impaired older individuals, judgments about occupational competence are often informed by an assessment of cognitive competence.

Purpose.

The Cognitive Competency Test (CCT) is a frequently used measure in Canada to inform predictions of occupational competence. However, there is an absence of published evidence that addresses its validity.

Methods.

To appraise validity of the CCT, a retrospective chart review ( n = 107) of CCT reports for inpatient and outpatient clients with cognitive impairment was conducted. Data were subjected to exploratory factor analyses to examine the factor structure, and the measure was compared with commonly used clinical variables reflecting cognitive and occupational competence.

Findings.

Results suggest that the CCT measures a unitary construct and provide some support for its predictive capacity.

Implications.

CCT scores can add incremental validity to cognitive screens, such as the Mini Mental State Exam, when evaluating occupational competence.

Economic analysis of the intangible impacts of informal care for people with Alzheimer's disease and other mental disorders

OBJECTIVES

Valuation of the intangible impacts of informal care remains a great challenge for economic evaluation, especially in the framework of care recipients with cognitive impairment. Our main objective was to explore the influence of intangible impacts of caring on both informal caregivers' ability to estimate their willingness to pay (WTP) to be replaced and their WTP value.

METHODS

We mapped characteristics that influence ability or inability to estimate WTP by using a multiple correspondence analysis. We ran a bivariate probit model with sample selection to further analyze the caregivers' WTP value conditional on their ability to estimate their WTP.

RESULTS

A distinction exists between the opportunity costs of the caring dimension and those of the intangible costs and benefits of caring. Informal caregivers' ability to estimate WTP is negatively influenced by both intangible benefits from caring (P < 0.001) and negative intangible impacts of caring (P < 0.05). Caregivers' WTP value is negatively associated with positive intangible impacts of informal care (P < 0.01).

CONCLUSIONS

Informal caregivers' WTP and their ability to estimate WTP are both influenced by intangible burden and benefit of caring. These results call into question the relevance of a hypothetical generalized financial compensation system as the optimal way to motivate caregivers to continue providing care.

The relationship between functional status and judgment/problem solving among individuals with dementia

OBJECTIVE

To determine the relationship between functional status (independent activities of daily living) and judgment/problem solving and the extent to which select demographic characteristics such as dementia subtype and cognitive measures may moderate that relationship in older adult individuals with dementia.

METHODS

The National Alzheimer's Coordinating Center Universal Data Set was accessed for a study sample of 3,855 individuals diagnosed with dementia. Primary variables included functional status, judgment/problem solving, and cognition.

RESULTS

Functional status was related to judgment/problem solving (r = 0.66; p < 0.0005). Functional status and cognition jointly predicted 56% of the variance in judgment/problem solving (R(2) = 0.56, p < 0.0005). As cognition decreases, the prediction of poorer judgment/problem solving by functional status became stronger.

CONCLUSIONS

Among individuals with a diagnosis of dementia, declining functional status as well as declining cognition should raise concerns about judgment/problem solving.

The primary care diagnosis of dementia in Europe: an analysis using multidisciplinary, multinational expert groups

OBJECTIVES

To explore the extent of variation in the detection of dementia in primary care across Europe, and the potential for the development of European guidelines.

METHOD

A mixture of focus group and adapted nominal group methods involving 23 experts of different disciplines and from eight European countries.

RESULTS

The diagnosis of dementia should be 'timely' rather than 'early'. Timeliness has an impact on the patient, on the caregiver, on healthcare professionals, and on society. Ethical and moral issues may interfere with the aim of timely diagnosis. Guidelines may be important for facilitating a timely diagnosis of dementia, but were infrequently used and not even available in three of the eight countries. Referral pathways often depended on health care system characteristics, differing throughout the eight European countries, whilst diagnostic strategies differed due to varied cultural influences. There was consensus that national variations can be reduced and timely diagnosis enhanced by combining simple tests using a systematic stepwise case-finding strategy, in conjunction with a strong infrastructure of multidisciplinary collaboration.

CONCLUSIONS

This study identified three key themes that should be considered in harmonizing European approaches to the diagnosis of dementia in primary care: (1) a focus on timely diagnosis, (2) the need for the development and implementation of guidelines, and (3) the identification of appropriate referral pathways and diagnostic strategies including multi-professional collaboration. The content of guidelines may be determined by the perspectives of the guideline developers.

The diagnosis of dementia: diagnostic accuracy of an instrument measuring activities of daily living in a clinic-based population

BACKGROUND/AIMS

Since widely accepted definitions of dementia encompass impairments in social and occupational, as well as cognitive, function, we investigated the diagnostic accuracy of Lawton and Brody's Instrumental Activities of Daily Living (IADL) Scale as an independent test for the diagnosis of dementia.

METHODS

The IADL Scale was administered to consecutive referrals to 2 memory clinics over a 2-year period, independent of other tests (interview, neuropsychology, imaging) which were used to establish diagnoses according to standard diagnostic criteria, and the results were compared.

RESULTS

In a cohort of 296 patients, 52% adjudged to have dementia, IADL Scale scores and subscores showed low sensitivity, specificity, and positive and negative predictive values for the diagnosis of dementia. The likelihood ratios, a measure of diagnostic gain, were generally small to unimportant, and diagnostic accuracy as measured by area under the receiver operating characteristic curve was no better than 0.75.

CONCLUSION

IADL Scale scores are not very helpful in making a diagnosis of dementia. More sensitive scales may be required to detect dementia-related functional decline, although it is also possible that dementia syndromes may be present in the absence of functional decline, challenging accepted definitions of dementia.

[Initial treatment of patients with subjective memory complaints and/or cognitive impairment in primary care: ISSEA Study]

OBJECTIVE

To describe the initial treatment of patients >60 years who had subjective memory complaints and/or cognitive impairment for at least 6 months.

DESIGN

Observational, longitudinal, multicentre, and naturalistic study, with a follow-up period of 12 months.

SETTING

A total of 105 primary care centres.

PARTICIPANTS

The study included 921 patients who attended a clinic.

MAIN MEASUREMENTS

In the baseline visit, the social demographic characteristics, diagnosis, treatment, and the health care referrals were recorded, and in the next 2 (6 and 12 months) the diagnostic change, treatment, and referrals.

RESULTS

The majority of subjects were female (66.9%) and the mean age was 74.3+/-6.8 years. In the initial visit, 50.5% (95% confidence interval [CI], 47.3-53.7) of the diagnoses were classed as syndromic and 33.3% (95% CI, 30.3-36.3), aetiological. The primary care doctor modified an unconfirmed initial diagnosis in 22% (95% CI, 19.3-24.7) of the patients during the 12 months follow-up study. A diagnosis was made in 63.8% (95% CI, 60.7-66.9) of patients by anamnesis, physical examination, the screening test, and laboratory data. In the initial visit, el 52.6% (95% CI, 49.4-55.8) received treatment of mainly nootropics and neuroprotectors, and later, the percentage of patients on cholinesterase inhibitors increased. The primary care doctor referred 54.9% (95% CI, 51.7-58.1) of the patients during the 12 months of the study.

CONCLUSIONS

The primary care doctor diagnoses the majority of patients with the means available, mainly based on anamnesis, examination, the screening test, and laboratory data. They prescribe drugs that lack efficacy for this disease and few of those that have been shown to be effective.

Comparative validity of seven scoring systems for the instrumental activities of daily living scale in rural elders

Lawton and Brody's eight-item Instrumental Activities of Daily Living (IADL) scale is used often with elderly patients but scored in several different ways. We scored the IADL with seven popular procedures ranging from relatively simple to complex (Guttman scores, summed and Rasch scores from dichotomous, trichotomous, and polytomous items) in a sample of rural elders (N = 231). We compared the IADL scales' prediction of concurrent cognitive functioning, depressive symptoms, psychosocial functioning, and health care use (medications, outpatient visits, inpatient days). Validity coefficients ranged from small to large among outcome variables but were highly consistent across IADL scoring procedures. Consequently, researchers and clinicians may prefer to use simpler IADL scoring procedures with this population.

Identification and diagnostic evaluation of possible dementia in general practice. A prospective study

OBJECTIVE

To investigate the rate of diagnostic evaluation of dementia for patients in whom a suspicion of dementia was raised, and to investigate reasons why a diagnostic evaluation was not always being performed.

DESIGN

A prospective study among elderly patients aged 65+, and a follow-up study.

SETTING

In all, 17 general practices in Copenhagen with 40 865 patients on their lists of whom 2934 were aged 65+.

SUBJECTS

A total of 793 patients consulting their GP regardless of reason of encounter, in October and November 2002.

MAIN OUTCOME MEASURES

MMSE score < or = 23, GP clinical impression of dementia, laboratory-screening tests prescribed by the GPs and referral status after 6 months, and follow-up questionnaire.

RESULTS

Of 793 patients a total of 138 patients were identified with possible dementia. Among the identified patients 26 (20%) were referred for further evaluation within 6 months, and 4 (3%) were treated for depression or referred for another condition. A total of 6 patients were lost to follow-up. In the remaining 102 undiagnosed patients the main reasons for not performing a diagnostic evaluation of dementia were patient/relative hesitation (34%), the GP thought that it would not have any consequences for the patient, or the GP estimated that the patient was too fragile (21%).

CONCLUSION

In 17% of elderly patients in general practice a suspicion of dementia could be raised based on the clinical impression of the GP or MMSE score. However, only 23% of this group were evaluated by their GP or referred to a memory clinic within a subsequent period of 6 months.

Functional neuroimaging indicators of successful executive control in the oldest old

Attentional control, motor planning abilities, and executive cognitive functions (ECF) rapidly decline with age. In particular, older adults experience difficulty in manipulating selected motor responses in the presence of conflicting or distracting information. To examine age-related changes in the neural substrates of the attentional and motor planning components of ECF, we assessed the patterns of brain activation in 8 cognitively normal older adults (mean age 81.5) and 20 young individuals (mean age 23.0) while they responded to low and high loads of attentional demands of the Preparing to Overcome Prepotency (POP) task. In the POP task, the selection of one out of two possible motor responses in the presence of increasing attentional task loads determines the accuracy of the performance. Older individuals were slower than young adults (P < 0.001) but achieved a strikingly high accuracy similar to the young group (P = 0.2), regardless of the task load. Both groups showed a load-related fMRI signal increase in the anterior cingulate cortex (ACC), posterior parietal cortex (PPC: Brodmann areas 7 and 40), and dorsolateral prefrontal cortex (dLPFC: Brodmann areas 9, 45, and 46) bilaterally. Compared to young individuals, older adults had lower activation in dLPFC (Brodmann areas 9, 45, and 46: P = 0.007, P = 0.043, and P = 0.040) and Brodmann area 7, P = 0.002. Activation in Brodmann areas 40 and ACC was similar in the two groups (P > 0.05). Among older adults, the most successful performers were those who responded to increasing task loads with greater activation in PPC (Brodmann area 40), despite lower dLPFC activation. Older adults who are able to perform executive control tasks as well as young adults, also seem to implement speed-accuracy trade-off strategies which may rely on increased parietal activation.

Factors affecting timely recognition and diagnosis of dementia across Europe: from awareness to stigma

BACKGROUND

Timely recognition and diagnosis of dementia is the pre-condition for improving dementia care, but diagnosis often occurs late in the disease process.

OBJECTIVE

To compare facilitators and obstacles to the timely recognition of dementia across eight European Union states, in order to implement established policies for earlier diagnosis.

METHODS

A modified focus group technique, including a pre and posterior procedure.

RESULTS

Twenty-three participants from different disciplines, purposively sampled for professional expertise in dementia research and innovative practice, attended two focus groups. Stigma in ageing and dementia, accompanied by a sense that there is little to offer until later on in the disease, underpinned the widespread reluctance of GPs to recognise dementia at an early stage and were major obstacles to the timely diagnosis of dementia across all eight countries. Dementia care services varied widely across Europe. Countries with the greatest development of dementia health care services were characterised by national guidelines, GPs fulfilling a gatekeeper function, multi-disciplinary memory clinics and innovative programmes that stimulated practice and new services. Dementia-related stigma was perceived as being less prominent in these countries.

CONCLUSIONS

Overcome of delays in the timely diagnosis of dementia needs more than specialist services. They should address the processes associated with stigma, age and dementia, especially where these relate to physician practice and diagnostic disclosure. Stigma is perceived as variable across European States, with a promising finding that its impact is relatively small in countries with the widest range of dementia care services.