Utility of Mini-Mental State Exam scores in predicting functional impairment among white and African American dementia patients

Early strong predictors of decline in instrumental activities of daily living in community-dwelling older Japanese people

Objective

Our aim is to determine the strong predictors of the onset of instrumental activities of daily living (IADL) decline in community-dwelling older people.

Design

A prospective cohort study with a two-year follow-up.

Setting

Kashiwa City, Chiba Prefecture, Japan and Toshima Ward, Tokyo Metropolitan, Japan.

Participants

The data were acquired from two cohorts. The final sample comprised 1,523 community-dwelling older people aged 65–94 years (681 men, 842 women). They were individuals who were independent in IADL at baseline and participated in follow-up IADL assessments two years later.

Measurements

At baseline, comprehensive assessments were performed including: health interview, gait function, hand-grip strength, skeletal muscle mass, balance function, oral function, dietary lifestyle, cognitive function, quality of life, mental status, and social network. When the two-year follow-up was performed, IADL declines were observed in 53 out of 1,523 people. The association of each Z-transformed parameter with the occurrence of IADL decline was examined by employing a binominal logistic regression model adjusting for age, gender, body weight, body height, and medical history. An odds ratio (OR) and a 95% confidence interval were calculated and compared between different parameters.

Results

A decrease in walking speed and one-legged stance time, whereas an increased timed up & go test time was associated with significant ORs for the occurrence of IADL decline.

Conclusion

Gait-related parameters appear to be the strong predictors of the onset of IADL decline in community-dwelling older people.

Usefulness of the University of California San Diego Performance-Based Skills Assessment for the evaluation of cognitive function and activities of daily living function in patients with cognitive impairment

OBJECTIVES

To assess the usefulness of the University of California San Diego Performance-Based Skills Assessment (UPSA) as a new diagnostic method and tool for the assessment of cognitive function and activities of daily living function in patients with cognitive impairment.

METHOD

In total, 35 patients with cognitive impairment and 35 healthy controls were recruited for this study. The Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), and Global Deterioration Scale (GDS) were used for the evaluation of cognitive function, while the Barthel Activities of Daily Living Index (BADL), Instrumental Activities of Daily Living Index (IADL), and UPSA were used for the evaluation of activities of daily living function.

RESULTS

UPSA scores were significantly lower in patients with cognitive impairment than in controls. The UPSA total score was significantly correlated with MMSE, CDR, GDS, and IADL scores. With regard to the detection of cognitive impairment, UPSA exhibited a greater determination power (R² = 0.593) compared with BADL (R² = 0.149) and IADL (R² = 0.423) and higher sensitivity and specificity compared with IADL.

CONCLUSION

Our results suggest that UPSA is a useful tool for the evaluation of cognitive function and activities of daily living function in patients with cognitive impairment.

Using Big Data in oncology to prospectively impact clinical patient care: A proof of concept study

OBJECTIVE

Big Data is widely seen as a major opportunity for progress in the practice of personalized medicine, attracting the attention from medical societies and presidential teams alike as it offers a unique opportunity to enlarge the base of evidence, especially for older patients underrepresented in clinical trials. This study prospectively assessed the real-time availability of clinical cases in the Health & Research Informatics Total Cancer Care™ (TCC) database matching community patients with cancer, and the impact of such a consultation on treatment.

MATERIALS AND METHODS

Patients aged 70 and older seen at the Lynn Cancer Institute (LCI) with a documented malignancy were eligible. Geriatric screening information and the oncologist's pre-consultation treatment plan were sent to Moffitt. A search for similar patients was done in TCC and additional information retrieved from Electronic Medical Records. A report summarizing the data was sent and the utility of such a consultation was assessed per email after the treatment decision.

RESULTS

Thirty one patients were included. The geriatric screening was positive in 87.1% (27) of them. The oncogeriatric consultation took on average 2.2 working days. It influenced treatment in 38.7% (12), and modified it in 19.4% (6). The consultation was perceived as "somewhat" to "very useful" in 83.9% (26).

CONCLUSION

This study establishes a proof of concept of the feasibility of real time use of Big Data for clinical practice. The geriatric screening and the consultation report influenced treatment in 38.7% of cases and modified it in 19.4%, which compares very well with oncogeriatric literature. Additional steps are needed to render it financially and clinically viable.

Subjective cognitive concerns are associated with objective memory performance in Caucasian but not African-American persons

Objective

subjective cognitive concerns (SCC) have been proposed as a means of identifying individuals at risk for Alzheimer's disease (AD). However, the utility of SCCs has not been well-explored for African-Americans, who are twice as likely to develop AD dementia as Caucasians. We investigated whether race affects the association between SCCs and objective memory performance.

Methods

we used a composite of three SCC questionnaires, and three challenging episodic memory tests. We studied 289 (61% female; African-American n = 47) clinically normal older individuals. Two hierarchical linear regressions assessed the modifying role of race on the association between SCC and objective memory performance. The first regression was conducted on the full sample, while the second matched the racial groups on age, estimated verbal IQ and socioeconomic status.

Results

in the full sample, both groups reported similar levels of SCCs, P = 0.10, although African-Americans performed worse on the memory tasks, P < 0.001. No group differences were observed in the matched sample. The SCC × race interaction term was nonsignificant in the full sample, β = 0.109, P = 0.09, but was significant in the matched sample, β = 0.422, P = 0.037. While a significant correlation was observed between SCCs and memory among Caucasians, r = -0.401, the correlation was not found among African-Americans, r = -0.052.

Conclusions

results suggest that the dissociation between SCCs and memory performance in African-Americans may indicate qualitative differences in how diverse groups endorse cognitive concerns, even after considering socioeconomic and educational factors.

Characteristics of Depressed Caregivers of Veterans With Dementia

This study examined the characteristics of caregivers and persons with dementia (PWD) to determine their association with caregiver depression. Participants included 508 PWD (veterans) and 486 caregivers from Boston, Houston, Providence, Beaumont (Texas), and Oklahoma City, identified from diagnoses from medical records and recruited from February 2007 to July 2009, for a larger study evaluating Partners in Dementia Care, a care-coordination intervention. Characteristics evaluated for PWD included activities of daily living, instrumental activities of daily living, cognitive impairment, and disruptive behavior. Caregiver characteristics evaluated included caregiver unmet needs, support-service use, and number of informal helpers. Caregiver depression was measured using the Iowa form 11-item Center for Epidemiologic Studies Depression Scale. Depressed caregivers reported significantly more unmet needs than the nondepressed caregivers. Depressed caregivers also reported a high frequency of disruptive behavior in their PWD. Caregiver perceptions of unmet needs may be an important target for intervention.

Validation of the multimodal assessment of capacities in severe dementia: a novel cognitive and functional scale for use in severe dementia

The multimodal assessment of capacities in severe dementia (MAC-SD), a novel cognitive and functional assessment, was developed for use with patients with severe dementia. Its psychometric attributes were examined in a unicenter, open, observational study. The MAC-SD along with the Spanish language Severe Mini Mental Exam were administered to 103 patients with a diagnosis of severe dementia. Psychometric analyses were performed to determine acceptability, reliability, validity, and responsiveness. As a whole, the MAC-SD sections showed no floor effects, satisfactory internal consistency, reproducibility, construct validity, precision, and sensitivity to change. The MAC-SD performed as a useful, valid, and potentially responsive tool to measure cognition and functioning in the most advanced stages of dementia.

Neuroimaging indicators of the performance of instrumental activities of daily living in Alzheimer's disease combined with cerebrovascular disease

OBJECTIVES

The aim of the present study was to explore the magnetic resonance imaging correlates of the performance of instrumental activities of daily living (IADL) in patients with Alzheimer's disease combined with cerebrovascular disease.

METHODS

A total of 66 patients with Alzheimer's disease combined with cerebrovascular disease formed the study sample. Two regression models were constructed to find correlates of IADL. Model 1 only included clinical variables and model 2 included both clinical and magnetic resonance imaging variables.

RESULTS

In model 1, with IADL as the dependent variable, the Mini-Mental State Examination (MMSE) score, Physical Self-Maintenance Scale score at baseline and age were significant correlates accounting for 40.1% of the variance of IADL at baseline. MMSE score and age were also significant correlates of IADL at 6 months, accounting for 38.1% of the variance of it. In model 2, severity of white matter lesions, MMSE and Physical Self-Maintenance Scale scores at baseline significantly correlated with IADL at baseline, accounting for 52.1% of the variance of the dependent variables; severity of white matter lesions and MMSE significantly correlated with IADL at 6 months, accounting for 41.5% of the variance of the dependent variables.

CONCLUSION

In patients with Alzheimer's disease combined with cerebrovascular disease, subcortical ischemic lesions might be significant contributor to the functional status.

Understanding the Outcomes Measures used in Huntington Disease Pharmacological Trials: A Systematic Review

BACKGROUND

The identification of the gene mutation causing Huntington disease has raised hopes for new treatments to ease symptoms and slow functional decline. As such, there has been a push towards designing efficient pharmacological trials (i.e., drug trials), especially with regard to selecting outcomes measures that are both brief and sensitive to changes across the course of the disease, from subtle prodromal changes, to more severe end-stage changes.

OBJECTIVES

Recently, to aid in efficient development of new HD research studies, the National Institute of Neurological Disorders and Stroke (NINDS) published recommendations for measurement selection in HD. While these recommendations are helpful, many of the recommended measures have little published data in HD. As such, we conducted a systematic review of the literature to identify the most common outcomes measures used in HD clinical trials.

METHODS

Major medical databases, including PubMed, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials, were used to identify peer-reviewed journal articles in English from 2001 through April 2013; 151 pharmacological trials were identified.

RESULTS

The majority of HD clinical trials employed clinician-reported outcomes measures (93%); patient reported outcome measures (11%) and observer reported outcome measures (3%) were used with much less frequency.

CONCLUSIONS

We provide a review of the most commonly used measures across these trials, compare these measures to the clinical recommendations made by the NINDS working groups, and provide recommendations for selecting measures for future clinical trials that meet the Food and Drug Administration standards.

Associations between self-rated vision score, vision tests, and self-reported visual function in the Salisbury Eye Evaluation Study

PURPOSE

We attempt to understand the determinants of self-rated vision status by examining associations with vision tests, self-reported visual function, demographic, and health-status characteristics.

METHODS

Participants included 2467 individuals, aged 65 to 84 years, in a longitudinal, population-based cohort study. Participants rated their vision status from 0 to 10. Visual acuity, contrast sensitivity, stereoacuity, and visual fields were assessed. The Activities of Daily Vision Scale (ADVS) questionnaire was administered. Multivariate ordinal and multinomial logistic-regression models examined the association of demographic, health-status characteristics, vision tests, and ADVS subscales with self-rated vision status score. Odds ratios described the association of these characteristics with reporting better vision status.

RESULTS

Better visual acuity, contrast sensitivity, stereoacuity, and visual fields were associated with increased odds of reporting better vision status. Among the vision tests, a 2-line increase in visual acuity was most likely to result in an individual reporting better vision status (odds ratio, 1.49; 95% confidence interval [CI], 1.30-1.70). A 5-point increase in the near vision and far vision ADVS subscale scores was associated with increased odds of reporting good versus poor vision status. A 5-point increase in the near vision subscale was most likely to result in an individual reporting good versus poor vision status (odds ratio, 1.38; 95% CI, 1.28-1.50).

CONCLUSIONS

Self-rated vision status is a multidimensional measure. Near-vision visual function, visual acuity, and contrast sensitivity are important determinants of self-rated vision status in an elderly population. This understanding may improve the ability of eye care providers to maximize self-rated vision status among their patients.

Aspects of Attention Predict Real-World Task Performance in Alzheimer's Disease

More research is needed to examine the relationship between specific neuropsychological functions and observation-based daily activity tests in patients with Alzheimer's disease (AD). Fifty-six patients with AD were administered tests of attention and processing speed and an observation-based activities-of-daily-living (ADL) task. Complex short-term attention capacity best predicted real-world task performance, accounting for several domains of ADL functioning. These results suggest that complex attention requiring working-memory systems, but not simple attention or processing speed, account for moderate portions of variability in daily task performance. These results may aid in understanding the attentional processes required for performing daily activities and can be useful to health care professionals in treatment planning.

Urinary Urgency Medications May Compromise Discrete rather than Global Cognitive Skills

BACKGROUND/AIMS

Prior research about cognitive problems associated with the use of urinary urgency medication (UUM) has reported mixed results that suggest procedures and/or assessments may need to be refined.

METHODS

Ten elderly subjects who were actively taking a UUM were assessed with neuropsychological testing before and after a 4-week UUM washout period. Results were evaluated by examining discrete subtest results, full-scale scores, and the reliable change index methodology.

RESULTS

Four controls and 5 subjects with mild cognitive impairment showed significant improvement in at least one subtest score on well-characterized instruments.

CONCLUSION

In this case study of 10 subjects, withdrawal of oxybutynin and tolterodine resulted in significant changes in subtest scores with different patterns for each subject that were not necessarily reflected in their total scores. Thus, future clinical studies should always include analysis of subtest results as these changes may be the only indication that cognition has been improved or has declined significantly.

Clinical outcomes and low-dose levocarnitine supplementation in psychiatric inpatients with documented hypocarnitinemia: a retrospective chart review

BACKGROUND

Metabolic encephalopathy is one of the crucial manifestations of carnitine deficiency. In psychiatric patients, low serum carnitine levels may result from chronic valproate therapy. Despite the widespread use of valproate in psychiatry, neither carnitine deficiency nor supplementation has been studied in a psychiatric population.

OBJECTIVE

To describe clinical outcomes in hospitalized psychiatric patients with documented hypocarnitinemia who were receiving oral levocarnitine supplementation.

METHOD

Retrospective chart review.

RESULTS

In 38 patients with hypocarnitinemia, a low-dose oral levocarnitine supplementation, in association with comprehensive psychiatric therapy, did not result in any adverse psychiatric or medical outcomes, and was associated with overall improved behavioral, cognitive, and motor functioning. Initially all patients had some degree of cognitive impairment, but after correction of carnitine serum levels, scores on the Mini-Mental State Examination (MMSE) improved in most of the patients (mean improvement 5.5 points, P <0.0001), and normalized in 11 cases. This allowed a correction of the diagnosis in 8 of 14 patients who had initially been diagnosed with dementia. African-American patients achieved significantly lower serum carnitine levels and MMSE scores than Caucasian patients with comparable therapy.

CONCLUSION

We hypothesize that correction of carnitine depletion, either by levocarnitine supplementation or by valproate dose reduction, may enhance recovery from hypocarnitinemia-associated encephalopathy in psychiatric patients. Our findings also suggest that ethnic traits may affect carnitine bioavailability as well as cognitive outcomes in this clinical context. Further studies of carnitine metabolism and supplementation in psychiatric patients are warranted.

Predicting everyday functional abilities of dementia patients with the Mini-Mental State Examination

The Mini-Mental State Examination is a widely used cognitive screening measure. The purpose of the present study was to assess how 5 specific clusters of Mini-Mental State Examination items (ie, subscores) correlate with and predict specific areas of daily functioning in dementia patients, 61 patients with varied forms of dementia were administered the Mini-Mental State Examination and an observation-based daily functional test (the Direct Assessment of Functional Status). The results revealed that the orientation and attention subscores of the Mini-Mental State Examination correlated most significantly with most functional domains. The Mini-Mental State Examination language items correlated with all but the shopping and time orientation tasks, while the Mini-Mental State Examination recall items correlated with the Direct Assessment of Functional Status time orientation and shopping tasks. Stepwise regression analyses found that among the Mini-Mental State Examination subscores, orientation was the single, best independent predictor of daily functioning.

Change in direct measures of physical performance among persons with Alzheimer's disease

OBJECTIVES

Measures of physical performance were used in intact and community populations. We examined upper and lower extremity physical performance tests among people with Alzheimer's disease.

METHOD

A total of 367 persons with probable Alzheimer's disease, recruited from an Alzheimer's disease diagnostic center, were given three tests of lower extremity function and two tests of upper extremity function at 6 month intervals for up to 4 years. Gender, race, age and Mini-Mental State Examination (MMSE) score at baseline were used to predict subsequent decline in composite scores of lower and upper extremity function.

RESULTS

At baseline, older age and lower MMSE scores were associated with lower scores on both lower and upper extremity function. Males performed better at baseline on lower extremity tests only. For each point higher on MMSE, a person declined 0.023 Standard Unit (SU) less per year (p = 0.0001) on lower extremity tests and declined 0.019 SU less per year (p < 0.0001) on upper extremity tests.

CONCLUSION

Physical performance was measured across a range of disease severities and declined over time. Lower cognitive score at baseline predicted faster decline in both lower and upper extremity function. Demographic heterogeneity in decline suggests other predictors may identify factors protective against physical decline.

African Americans with memory loss: findings from a community clinic in Lexington, Kentucky

Kentucky's African-American Dementia Outreach Partnership (AADOP) has shown that African-American patients seek dementia care if a clinic is conveniently located and families are educated about the distinction between normal aging and signs of disease. The early identification of dementia allows African Americans access to pharmaceutic treatments that work best early in the course of the disease and provides the opportunity for the patient to plan future care. In the AADOP model, a conveniently located clinic and access to the patient's home were first steps in achieving equality of care. The trust that was built in the community through collaboration with African-American churches has allowed patients and their families to receive help with memory problems and to feel comfortable in seeking help for other medical problems. Maintaining this involvement and responsiveness to the community over the long term is the next challenge for the program.

The prevalence of dementia in an urban Turkish population

A cross-sectional, population-based, 2-stage prevalence study was conducted in a sample of 1019 community-dwelling persons over the age of 70 years living in Istanbul. In the first phase, participants were screened with the Mini-Mental State Examination for evidence of cognitive impairment. In the second phase, 79% of those who screened positive (n = 322) and 9% of screen-negatives (n = 63) underwent a standardized diagnostic workup. Diagnosis of dementia and Alzheimer's disease (AD) was made according to established criteria. Ninety-three cases of dementia were identified, 58 of whom were diagnosed with probable AD. Based on these numbers, the prevalence rates of probable AD and dementia were calculated to be 11.0% (95% CI, 7.0% to 15.0%) and 20.0% (95% CI, 14.0% to 26.0%), respectively, in this population. Prevalence rates of dementia and AD in Istanbul, Turkey, are comparable with those seen in the Western world.

A direct functional measure to help ascertain optimal level of residential care

A brieF direct measure oF daily living skills might help place cognitively impaired elders in suitable living environments. In this study, the Test oF Everyday Functional Abilities (TEFA) as a possible adjunctive measure was investigated. The authors recruited 77 cognitively impaired persons in independent living (IL; N = 26), assisted living (AL; N = 25), and dementia special care (SC; N = 26) units. Participants in IL and AL were administered the TEFA and other instruments at baseline and every 6 months over 18 months and when transFerred to a higher level oF care. Special care subjects were administered the same instruments only at baseline. The TEFA clearly separated IL, AL, and SC residents (P < .0001). A TEFA score >50 suggests adequate Functional competence For IL; a score From 30 to 40 adequate Functional competence For AL; and a score oF <30 probable need For an SC unit in the absence oF a capable spouse.

Ethnic and educational differences in cognitive test performance on mini-mental state examination in Asians

OBJECTIVE

The objective of this study is to examine ethnic differences in Mini-Mental State Examination (MMSE) test performance in discriminating between demented and nondemented elderly Asians.

METHODS

A nationally representative population sample (N = 1,092) of community-living elderly, comprising Chinese, Malays, and Indians in Singapore, was interviewed using MMSE, Geriatric Mental State, and demographic and health questionnaires.

RESULTS

There were significant ethnic differences in mean MMSE scores among Chinese (26.2), Indians (25.0), and Malays (23.6), but only in noneducated subjects. No ethnic differences in MMSE were observed in higher educated subjects. The sample proportion of subjects with dementia was 4.2% in Chinese, 9.4% in Malays, and 8.8% in Indians. Overall, MMSE discriminated well between subjects with and without dementia (cutoff: 23/24, area under the curve: 95%, sensitivity: 97.5%, specificity: 75.6%). MMSE test performance was much better in higher educated subjects (higher specificity: 85.2%). Lower specificities were shown in less educated subjects (57.3%), and in Malays (62.8%), and especially in less educated Malays (35.3%) and Indians (50.0%). Significant differences in MMSE scores in less educated subjects persisted after adjusting for differences in sociodemographic, health, and behavioral variables

CONCLUSION

Ethnic nonequivalence in MMSE test performance should be taken into account in dementia screening in Asians in less educated subjects. Known correlates of cognitive functioning did not sufficiently explain these differences.

Relationship between executive functioning and activities of daily living in patients with relatively mild dementia

There is very little research regarding the relationship between tests of executive functioning and actual functional ability in patients with dementia. Thirty-three patients diagnosed with dementia and 35 age- and education-matched healthy controls were administered tests of executing functioning and an observation- and informant-based activities of daily living (ADL). As expected, the results revealed that the controls outperformed the dementia patients on the executive and ADL tests. Additionally, executive functioning correlated significantly with aspects of functional ability in patients with dementia. This relationship was strongest for tests of verbal fluency and a complex test of cognitive flexibility and reasoning ability (i.e., Wisconsin Card Sorting Test). These findings suggest that some executive function tests are more sensitive than others for predicting specific functional abilities and that they may be most useful to healthcare professionals for treatment planning.

Early Environmental Factors, Ethnicity, and Adult Cognitive Test Performance

This study was conducted to better understand cross-cultural variation in neuropsychological test performance by exploring the relationship between early environmental factors and adult neuropsychological functioning in African Americans (AA) and Caucasians (CA). Cognitive testing data and detailed retrospective early environmental histories were obtained from 100 neurologically healthy adults (75 AA, 25 CA). Results indicate that: (a) consistent with previous research, the two ethnic groups differed significantly on their cognitive test performance; (b) early environmental factors were significantly related to performance on cognitive tests; (c) the two ethnic groups demonstrated slight, but significant, differences in their early environmental histories; but (d) covarying early environmental factors did not substantially reduce the group performance in cognitive test performance. The failure of reported environmental factors to account for more of the ethnic disparity in test performance may have resulted from the inherent weakness of the retrospective assessment method (i.e., lack of precision or objectivity in participants' recollections of their early environments). These results highlight the remaining need for ethnicity specific normative data until cross-cultural variation in neuropsychological test performance is better understood.

Functional impairment, healthcare costs and the prevalence of institutionalisation in patients with Alzheimer's disease and other dementias

INTRODUCTION

The progressive decline in functional status for patients with Alzheimer's disease and other dementias (ADOD) is well documented. However, there is limited information on the economic benefits of interventions improving functional status in an ADOD population. This study estimated the relationship between the degree of functional impairment in patients with ADOD and their healthcare costs and prevalence of institutionalisation.

METHODS

Retrospective cross-sectional analyses of the Medicare Current Beneficiary Survey (MCBS) were performed. A nationally representative sample of Medicare beneficiaries with ADOD was identified from the 1995-8 waves of the MCBS (n = 3138): 34% in the community, 57% institutionalised and 9% residing in both settings during the year. Three measures of functioning were used: the number of activities of daily living (ADLs) and independent ADLs (IADLs) impaired; an index summarising number and severity of ADL and IADL impairments; and the Katz Index of ADLs. Healthcare costs included costs for all healthcare services received in all settings, regardless of whether they were covered by insurance or paid out of pocket. The relationships between each measure of impairment and healthcare costs and prevalence of institutionalisation were estimated using linear and logistic regression.

RESULTS

Healthcare costs (1995-8 values) for all ADOD patients increased by 1,958 US dollars (p < 0.001) for each additional ADL impairment and 549 US dollars (p = 0.073) for each additional IADL impairment. For community-dwelling ADOD patients, healthcare costs increased by 1,541 US dollars (p < 0.001) for each additional ADL and 714 US dollars (p = 0.022) for each additional IADL. Costs also increased by severity on the summary index and the Katz Index. Odds of institutionalisation also increased by the three measures of functional impairment.

CONCLUSION

Although relationships between function and costs have been described previously, the exact nature of these relationships has not been investigated solely in patients with dementia. The data from this study suggest a strong relationship between functional impairment and healthcare costs, specifically in patients with dementia. Even IADL impairments, which are common in mild to moderate dementia, may significantly raise costs. The results suggest that therapies and care management that improve functioning may possibly reduce other healthcare costs.

Impediments to timely diagnosis of Alzheimer's disease in African Americans

The purpose of this study was to identify early patterns of care for Alzheimer's disease (AD) in a cohort of African-American patients and their caregivers presenting at an inner city clinic and a suburban memory assessment clinic. Caregivers (N=79) of patients diagnosed with probable AD were interviewed. Data were collected about the delay from noticing first AD signs until recognition that a problem existed and delay from problem recognition until first physician consultation. Patients and caregivers had lower educational status, and patients had been diagnosed more recently at the inner city clinic than at the suburban clinic, although MMSE scores of patients at the two clinics did not differ; median delays in caregivers' recognizing a problem and in consulting a physician were also similar across clinics. Delay was as long as 7 years between noticing symptoms and problem recognition and between problem recognition and physician consultation. Although patients attending the suburban clinic were more likely to have previously seen a physician than those attending the inner city clinic, they were no more likely to have received a prior diagnosis of AD. Lack of physician contact is likely to be widespread in families caring for African Americans with AD. Physician consultation is more characteristic of more highly educated families but may not yield a correct diagnosis for the patient. Intensive efforts are needed to connect African-American families with physicians and to achieve more timely diagnosis of AD to enable families to understand the illness, plan for patient safety, and make long-term plans.

Neuropsychological Testing

Neuropsychological testing is important for the diagnosis and follow-up of dementia; it can also help provide consultation on patient care. However, lengthy testing is costly and can be stressful to the subjects. Tests developed for members of the majority culture often are inappropriate for ethnic minorities, especially those who speak a different language, have little or no formal education, and grew up in vastly different circumstances. Variables that directly affect test performance, such as education and acculturation instead of race or ethnicity, should be considered as explanatory variables for test performance. Reading level may be a better index for educational attainment than the number of years in school. Neuropsychological testing can be improved in several directions: (1) Use tests that are appropriate for the subject's background. (2) Use detailed scoring of a smaller number of test items to reduce test time, and establish discontinuation rules to limit the subject's experience of failure. (3) Develop parallel test forms for repeated assessment of the same individuals. (4) Strive for large and representative standardization samples. (5) Use computerized test norms based on findings of statistical analysis to better adjust for confounding variables.

Galantamine Maintains Ability to Perform Activities of Daily Living in Patients with Alzheimer's Disease

OBJECTIVES

To examine the effect of galantamine on activities of daily living (ADLs) with respect to baseline dementia severity, correlation with cognitive and global function, specific ADLs affected, and maintenance of ADL independence.

DESIGN

Secondary analysis of a 5-month randomized, placebo-controlled trial.

SETTING

Multiple U.S. clinical centers.

PARTICIPANTS

Six hundred fifty-nine patients with mild to moderate Alzheimer's disease (AD) who completed 5 months of treatment.

INTERVENTION

Galantamine at a maintenance dose of 16 or 24 mg/d.

MEASUREMENTS

The AD Cooperative Study ADL Inventory (ADCS/ADL).

RESULTS

Galantamine resulted in more improvement in ADCS/ADL scores than placebo regardless of baseline dementia severity, with the greatest differences occurring in patients with more severe disease. Changes in ADCS/ADL scores correlated significantly with change scores on the cognitive subscale of the AD Assessment Scale (r=-0.24). Galantamine treatment resulted in maintenance or improvement of basic and instrumental ADLs, and change from baseline to Month 5 in scores for each individual ADL item favored galantamine over placebo in three of six basic ADLs and six of 17 instrumental ADLs.

CONCLUSION

Galantamine has a favorable effect on ADL performance in patients with AD, detectable after 5 months of treatment, regardless of dementia severity. The ADCS/ADL appears to better measure distinct abilities that may be relevant not only in clinical trials but also in individual patients than do cognitive assessments.

Assessing and predicting functional impairment in Alzheimer's disease: the emerging role of frontal system dysfunction

Alzheimer's disease (AD) is associated with neuropsychologic and neuropsychiatric dysfunction and is a leading cause of disability among the elderly. Impairments in activities of daily living (ADL) contribute significantly to the disability reported among patients with AD and diminish quality of life for patients and their families. ADL assessment represents an important component of the diagnosis, tracking, and management of AD. Further, an understanding of the determinants of ADL dysfunction is critical for the early identification of individuals at risk for functional disability and for improved patient care. This manuscript reviews methods for assessing ADL in patients with AD and summarizes the available literature on the neuropsychologic and neuropsychiatric correlates of functional impairment in AD. The emerging role of frontal system dysfunction as an important determinant of ADL impairment is discussed, and recommendations for clinical practice and future research are provided.

Medical comorbidity in black and white patients with Alzheimer's disease

BACKGROUND

Little is known about co-medical illnesses in black and white patients with probable Alzheimer's disease (AD).

METHODS

To address this question, we used two methods. In the first (Group I), black and white probable AD patients were matched on age at presentation to the clinic, age of onset of AD, duration of illness, and Mini-Mental State Examination scores; then, a variety of co-medical illnesses were compared between blacks and whites. In Group II, whites were randomly matched to blacks on the variables listed above.

RESULTS

In Group I, blacks were found to have a higher rate of hypertension than whites, whereas whites had a higher incidence of atrial fibrillation and cancer than blacks. In Group II, age at presentation to the clinic was found to be shorter for men than for women; duration of illness was shorter for black men than for white men, white women, and black women; and Mini-Mental State Examination scores were lower in blacks than whites. As in Group I, blacks were found to have a higher rate of hypertension, whereas whites had higher rates of atrial fibrillation, cancer, coronary artery disease, high cholesterol, and gastrointestinal disease.

CONCLUSION

In both groups, black patients with probable AD had a higher rate of hypertension than white patients with probable AD, and whites had higher rates of atrial fibrillation and cancer. This finding suggests that these comorbid illnesses in black and white patients with probable AD is not due to a statistical Type II error, but rather to differences in these groups.

Research agenda for understanding Alzheimer disease in diverse populations: work group on cultural diversity, Alzheimer's association

The emerging evidence of ethnic variations in apolipoprotein polymorphism and Alzheimer disease risk shows that one cannot generalize findings based on a single cultural group too broadly ( Tang et al., 2001). Presence of one apolipoprotein E epsilon 4 allele is a stronger risk factor for Alzheimer disease in whites and Asians than in blacks ( Farrer et al., 1997). Environmental or genetic cofactors may modulate the effects of epsilon 4 on beta-amyloid metabolism differently in different subpopulations ( Shadlen, 1998). Recognizing this, the Alzheimer's Association has extended its goals to strengthen the scientific information base on the interactions of population diversity and Alzheimer disease heterogeneity ( NIA, 1998). This new focus is timely since minority elderly are the most rapidly increasing segment of the elderly population ( Lilienfeld and Perl, 1994, Brookmeyer et al., 1998). In this article, the authors highlight recent progress in research on Alzheimer disease among culturally diverse populations with a special emphasis on gaps in the knowledge base. The authors recommend four priorities for future Alzheimer disease research: (1) determine whether genetic causative factors interact differently in different populations; (2) reexamine the nature and role of cerebral ischemia and infarction and variations in symptom severity of Alzheimer disease; (3) explore the interaction of genes and environmental influences that are protective against Alzheimer disease; and (4) recruit and enroll ethnically diverse subjects in Alzheimer disease clinical trials.

To what degree does cognitive impairment in Alzheimer's disease predict dependence of patients on caregivers?

BACKGROUND

Patients with Alzheimer's disease experience a progressive loss of cognitive function, and the ability to independently perform activities of daily life. Sometimes a dependent stage is reached quite early in the disease, when caregivers decide that the patients can no longer be left alone safely. This is an important aspect of Alzheimer's for patients, their families, and also health care providers. Understanding the relationship between a patient's current cognitive status and their need for care may assist clinicians when recommending an appropriate management plan. In this study, we investigated the relationship of cognitive function to dependence on caregivers before the patients reach a severe stage of the disease.

METHODS

Data were obtained on 1,289 patients with mild-to-moderate Alzheimer's disease studied in two randomised clinical trials of galantamine (ReminylcircledR;). Cognition was assessed using the cognitive part of the Alzheimer's Disease Assessment Scale (ADAS-cog) and Mini-Mental State Examination (MMSE). Patients were considered dependent if they required >12 hours of supervision each day or had high care needs. The Disability Assessment for Dementia (DAD) scale was also used as a measure of dependence. Disability was predicted directly using MMSE and ADAS-cog and compared to predictions from converted scores.

RESULTS

The odds ratio of dependence was significantly higher amongst the patients with worse cognitive impairment, adjusting for age, gender and antipsychotic medication use. For example, a 4-point difference in ADAS-cog score was associated with an increase of 17% (95% CI 11-23) in the adjusted odds for >12 hours of supervision, and of 35% (95% CI 28-43) for dependence. Disability predicted directly using actual ADAS-cog and scores converted from MMSE values had close agreement using the models developed.

CONCLUSION

In patients with mild-to-moderate Alzheimer's disease, even relatively small degrees of poorer cognitive function increased the risk of losing the ability to live independently.

Pain reports by older hospice cancer patients and family caregivers: the role of cognitive functioning

PURPOSE

Prior research in nursing homes has shown that cognitive impairment may reduce self-reported pain, but this relation has not been systematically explored among hospice patients. The assessment and treatment of pain is a primary goal of hospice care, and both disease processes and the use of opioid analgesics may lead to cognitive impairment among hospice patients. However, little is known about how cognitive functioning may impact the self-report of pain or the report of care recipient pain by family caregivers.

DESIGN AND METHODS

We explored the associations between pain, cognitive functioning, and gender among cancer patients and their family caregivers (N = 176 dyads) during in-home hospice care. This was a cross-sectional, correlational study.

RESULTS

Contrary to expectation, care recipients with cognitive impairment reported more intense pain than care recipients with intact cognitive functioning. However, cognitive impairment among care recipients had no impact on the pain report of family caregivers. Care recipient cognitive impairment was related to greater discrepancy in the pain reports of caregivers and care recipients. No gender differences in pain intensity report were found.

IMPLICATIONS

Measurement issues and implications for assessing self-reported pain among hospice cancer patients with impaired cognitive functioning and the report of care recipient pain by family caregivers are discussed. Specifically, hospice staff must educate family caregivers regarding the potential impact of care recipient cognitive impairment on pain reports in order to facilitate accurate pain assessment and management.

Evaluation and management of the driver with dementia

BACKGROUND

The number of older adult drivers with dementia is expected to increase over the next few decades. This increase raises public and personal safety concerns given the higher crash rates of drivers with a dementing illness. However, the identification of drivers with a dementia who may be at risk for a crash is difficult, particularly for those in the early stages of dementia.

REVIEW SUMMARY

Studies examining the correlation of dementia with driving outcomes such as motor vehicle crashes are reviewed. The strengths and weaknesses of recent consensus statements, published to assist clinicians in evaluating drivers with a dementia, are discussed. The authors also review common practices currently in use by physicians to identify at-risk drivers, including mental status examinations, global dementia rating scales, specialist referral, medical evaluations, and the use of caregiver reports and other proxy measures. Legal issues, based on the role of the physician, are reviewed along with suggestions for driving cessation and education for the caregiver and family.

CONCLUSIONS

In patients with mild to moderate dementia, the literature indicates that physicians would have difficulty in identifying which individuals should not drive. Performance-based measures of driving skills, such as on-road driving tests, are recommended as a means of assessing driving competency.

The hierarchy of functional loss associated with cognitive decline in older persons

OBJECTIVES

We studied a representative cohort of community-dwelling elderly persons to (i) examine the relationship between the loss of specific functional activities and cognitive status at the time of these losses, (ii) compare the cognitive status of participants who have and have not lost independence in these functional activities, and (iii) determine whether a hierarchical scale of functional loss is associated with declining cognitive status.

METHODS

A cohort of 5874 community-dwelling persons aged 65 years and older from the Canadian Study of Health and Aging I and II were analyzed. At baseline and 5 years later, cognitive status with the Modified Mini-Mental State Examination (3MS) and functional status with 14 Older American Resources and Services (OARS) items were measured. For each OARS functional item, the mean 3MS scores for persons who lost independence during the 5-year period versus those who did not were compared.

RESULTS

For each functional item, the 5-year decline in 3MS scores of persons who lost independence were significantly greater than those who remained independent (e.g., ability to do finances), with an 18-point decline for those who lost independence and a 2-point decline for those who retained independence. A hierarchy of functional items existed, with instrumental activities of daily living (ADLs) (e.g., shopping, banking, and cooking) being lost at higher cognitive scores than basic ADL items (e.g., eating, dressing, and walking), although there was some overlap.

CONCLUSIONS

This is the first prospective study using a large representative cohort of elderly persons to demonstrate that progressive cognitive decline is associated with a specific pattern of loss of functional tasks. Clear cognitive thresholds at which development of dependency in OARS functional items occurred. By providing estimates of the cognitive status of persons at the time at which they developed dependency in specific functional items, a natural hierarchy of functional loss associated with cognitive decline emerged. For caregivers, clinicians, and health policy makers, this information can help anticipate the pattern of functional decline and the subsequent care needs of persons with declining cognition, potentially improving the quality of life of these persons and their caregivers and playing an important part in health care planning.

Reading ability, education, and cognitive status assessment among older adults in Harlem, New York City

OBJECTIVES

This study examined reported level of education and current reading ability as predictors of cognitive status among older African Americans in central Harlem, New York City.

METHODS

A probability sample of 164 noninstitutionalized older African Americans was assessed. Mini-Mental State Examination (MMSE) scores were regressed on education and reading ability measures.

RESULTS

Reading ability and educational attainment were significant, independent predictors of MMSE performance. Within any level of education, subjects whose grade-equivalent reading ability exceeded reported level of education scored significantly higher on the MMSE.

CONCLUSIONS

Reading ability may be useful in interpreting the results of cognitive screening among low-educated and minority groups.