Communication abilities of individuals with late-stage Alzheimer disease

Early ultrasonic vocalization deficits and related thyroarytenoid muscle pathology in the transgenic TgF344-AD rat model of Alzheimer's disease

Background

Alzheimer's disease (AD) is a progressive neurologic disease and the most common cause of dementia. Classic pathology in AD is characterized by inflammation, abnormal presence of tau protein, and aggregation of β-amyloid that disrupt normal neuronal function and lead to cell death. Deficits in communication also occur during disease progression and significantly reduce health, well-being, and quality of life. Because clinical diagnosis occurs in the mid-stage of the disease, characterizing the prodrome and early stages in humans is currently challenging. To overcome these challenges, we use the validated TgF344-AD (F344-Tg(Prp-APP, Prp-PS1)19/Rrrc) transgenic rat model that manifests cognitive, behavioral, and neuropathological dysfunction akin to AD in humans.

Objectives

The overarching goal of our work is to test the central hypothesis that pathology and related behavioral deficits such as communication dysfunction in part manifest in the peripheral nervous system and corresponding target tissues already in the early stages. The primary aims of this study are to test the hypotheses that: (1) changes in ultrasonic vocalizations (USV) occur in the prodromal stage at 6 months of age and worsen at 9 months of age, (2) inflammation as well as AD-related pathology can be found in the thyroarytenoid muscle (TA) at 12 months of age (experimental endpoint tissue harvest), and to (3) demonstrate that the TgF344-AD rat model is an appropriate model for preclinical investigations of early AD-related vocal deficits.

Methods

USVs were collected from male TgF344-AD (N = 19) and wildtype (WT) Fischer-344 rats (N = 19) at 6 months (N = 38; WT: n = 19; TgF344-AD: n = 19) and 9 months of age (N = 18; WT: n = 10; TgF344-AD: n = 8) and acoustically analyzed for duration, mean power, principal frequency, low frequency, high frequency, peak frequency, and call type. RT-qPCR was used to assay peripheral inflammation and AD-related pathology via gene expressions in the TA muscle of male TgF344-AD rats (n = 6) and WT rats (n = 6) at 12 months of age.

Results

This study revealed a significant reduction in mean power of ultrasonic calls from 6 to 9 months of age and increased peak frequency levels over time in TgF344-AD rats compared to WT controls. Additionally, significant downregulation of AD-related genes Uqcrc2, Bace2, Serpina3n, and Igf2, as well as downregulation of pro-inflammatory gene Myd88 was found in the TA muscle of TgF344-AD rats at 12 months of age.

Discussion

Our findings demonstrate early and progressive vocal deficits in the TgF344-AD rat model. We further provide evidence of dysregulation of AD-pathology-related genes as well as inflammatory genes in the TA muscles of TgF344-AD rats in the early stage of the disease, confirming this rat model for early-stage investigations of voice deficits and related pathology.

The German version of the Mini Suffering State Examination (MSSE) for people with advanced dementia living in nursing homes

Background

The Mini Suffering State Examination (MSSE) has been explicitly recommended to assess suffering in dementia patients. This study aimed to develop a German version of the MSSE and assess its psychometric properties involving people with advanced dementia (PAD) in a nursing home setting.

Methods

The MSSE was translated into German, and 95 primary nurses administered it cross-sectionally to 124 PAD in Zurich, Switzerland. The psychometric properties of the German MSSE version were calculated for this population.

Results

The mean age of the PAD was 83.3 years (SD = 9.1, range = 55–102 years), and 98 of them (79.0%) were women. The Kuder-Richardson Formula 20 coefficient for the entire scale (0.58), the eight items relating to objective health conditions (0.39), and the professional and family estimation of the patient’s suffering (0.64) indicated low internal consistency. A confirmatory factor analysis indicated an unsatisfactory fit to a one-factor structure, with a comparative fit index and root mean square error of approximation of 0.71 and 0.08, respectively, and a Tucker–Lewis index of 0.64. The MSSE total score was significantly but moderately correlated with the total scores of the Symptom Management–End-of-Life with Dementia (SM-EOLD) scale (Pearson’s correlation coefficient (r) = -0.44; p < 0.05), the physical suffering scores (r = 0.41; p < 0.05), and the psychological suffering scores (r = 0.55; p < 0.05).

Conclusions

The German version of the MSSE questionnaire did not perform well in the nursing home setting involving PAD. The instrument had low internal consistency, doubtful validity, and could not discriminate between suffering and other distressing symptoms. We do not recommend its use in this population.

Association Between Alzheimer Disease and Cancer With Evaluation of Study Biases: A Systematic Review and Meta-analysis

IMPORTANCE

Observational studies consistently report inverse associations between cancer and Alzheimer disease (AD). Shared inverse etiological mechanisms might explain this phenomenon, but a systematic evaluation of methodological biases in existing studies is needed.

OBJECTIVES

To systematically review and meta-analyze evidence on the association between cancer and subsequent AD, systematically identify potential methodological biases in studies, and estimate the influence of these biases on the estimated pooled association between cancer and AD.

DATA SOURCES

All-language publications were identified from PubMed, Embase, and PsycINFO databases through September 2, 2020.

STUDY SELECTION

Longitudinal cohort studies and case-control studies on the risk of AD in older adults with a history of any cancer type, prostate cancer, breast cancer, colorectal cancer, or nonmelanoma skin cancer, relative to those with no cancer history.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently abstracted the data and evaluated study biases related to confounding, diagnostic bias, competing risks, or survival bias. Random-effects meta-analysis was used to provide pooled estimates of the association between cancer and AD. Metaregressions were used to evaluate whether the observed pooled estimate could be attributable to each bias. The study was designed and conducted according to the Preferring Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

MAIN OUTCOMES AND MEASURES

Incidence, hazard, or odds ratios for AD comparing older adults with vs without a previous cancer diagnosis.

RESULTS

In total, 19 cohort studies and 3 case-control studies of the associations between any cancer type (n = 13), prostate cancer (n = 5), breast cancer (n = 1), and nonmelanoma skin cancer (n = 3) with AD were identified, representing 9 630 435 individuals. In all studies combined, cancer was associated with decreased AD incidence (cohort studies: random-effects hazard ratio, 0.89; 95% CI, 0.79-1.00; case-control studies: random-effects odds ratio, 0.75; 95% CI, 0.61-0.93). Studies with insufficient or inappropriate confounder control or greater likelihood of AD diagnostic bias had mean hazard ratios closer to the null value, indicating that these biases could not explain the observed inverse association. Competing risks bias was rare. Studies with greater likelihood of survival bias had mean hazard ratios farther from the null value.

CONCLUSIONS AND RELEVANCE

The weak inverse association between cancer and AD may reflect shared inverse etiological mechanisms or survival bias but is not likely attributable to diagnostic bias, competing risks bias, or insufficient or inappropriate control for potential confounding factors.

Predictors of Perceived Social Support for Patients with Dementia: A Mixed-Methods Study

Purpose

Perceived social support (PSS) is closely linked to health outcomes in dementia patients. However, its continuous benefits are unclear. This mixed-methods study examined the impact of social support perceptions and differentiation among patients and carers during disease progression.

Patients and Methods

Persons with dementia (PWDs), family caregivers, and community family physicians were recruited from nine community health centers. Semi-structured interviews conducted with 12 PWDs (7 PWDs in mild dementia and 5 in moderate dementia), 12 family caregivers, and 6 community family physicians and conventional content analysis were used to explore social support perspectives at different dementia stages. A total of 470 PWDs were divided into mild (n=224), moderate (n=190), and severe (n=56) groups. Demographic, physical, and psychological factors related to PSS were examined by the group using multiple regression analysis. The group-based characteristics were entered into three prediction models.

Results

In the qualitative study, three themes of social support were identified: two viewpoints refer to social support; different needs and preferences in each stage; non-personalized support services. Quantitatively, the mild group scored lowest in perceived social support, while the severe group scored highest (χ²=64.70, P<0.001). The mild group PSS was predicted by depression (β=−0.07, P=0.04), cognitive capacity (β=−0.18, P<0.001), and instrumental ability (β=−0.78, P<0.001), which differed from the moderate and severe groups.

Conclusion

This study provided comprehensive insight into PSS from PWDs’ perspective at different stages of the disease. Results indicated the need for a stratified care approach and direction for further research on intervention.

Supporting communication for patients with neurodegenerative disease

BACKGROUND

Communication supports, referred to as augmentative and alternative communication (AAC), are an integral part of medical speech-language pathology practice, yet many providers remain unfamiliar with assessment and intervention principles. For patients with complex communication impairments secondary to neurodegenerative disease, AAC services differ depending on whether their condition primarily affects speech and motor skills (ALS), language (primary progressive aphasia) or cognition (Alzheimer's disease). This review discusses symptom management for these three conditions, identifying behavioral strategies, low- and high-tech solutions for implementation during the natural course of disease. These AAC principles apply to all neurodegenerative diseases in which common symptoms appear.

OBJECTIVES

To present AAC interventions for patients with neurodegenerative diseases affecting speech, motor, language and cognitive domains. Three themes emerge: (1) timing of intervention: early referral, regular re-evaluations and continual treatment are essential; (2) communication partners must be included from the onset to establish AAC acceptance and use; and (3) strategies will change over time and use multiple modalities to capitalize on patients' strengths.

CONCLUSIONS

AAC should be standard practice for adults with neurodegenerative disease. Patients can maintain effective, functional communication with AAC supports. Individualized communication systems can be implemented ensuring patients remain active participants in daily activities.

The Quality of Pain Treatment in Community-Dwelling Persons with Dementia

Purpose

Dementia of Alzheimer's type (DAT) is a major cognitive communication disorder. The present study attempted to analyse communication disorders in DAT in the International Classification of Functions (ICF) framework. The study investigated the impact of the severity of communication disorders in persons with DAT on activity participation and environment components of the ICF.

Method

Thirty bilingual individuals with DAT in the age range of 65-88 years were classified into three groups of mild, moderate and severe degree of dementia. Forty-three items of the American Speech-Language-Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS) were linked to the ICF framework. A few additional items were also added for a complete profiling of DAT. A total of 50 (ASHA FACS + ICF) items were rated and administered for the purpose of the study.

Results

The study revealed a disproportionate impact of the severity of DAT on activity participation and environment components of the ICF.

Conclusion

The present study investigated the utility of the ICF framework for profiling the functionality of persons with DAT. This profiling highlighted the need for ensuring effective communication and quality of life in the DAT population.

Examining success of communication strategies used by formal caregivers assisting individuals with Alzheimer's disease during an activity of daily living

PURPOSE

To examine how formal (i.e., employed) caregivers' use verbal and nonverbal communication strategies while assisting individuals with moderate to severe Alzheimer's disease (AD) during the successful completion of an activity of daily living (ADL). Based on the literature, the authors hypothesized that caregivers' use of 1 proposition, closed-ended questions, and repetition would be of most benefit.

METHOD

Twelve caregiver-AD dyads participated in this observational study. Each dyad was videorecorded on 6 separate occasions while completing handwashing. Handwashing sessions were transcribed and systematically coded for the use of communication strategies during completion of the ADL.

RESULTS

Caregiver-AD dyads successfully completed 90% of all handwashing sessions, and caregivers employed a variety of communication strategies. Consistent with our hypotheses, during successful task completion, caregivers most frequently provided individuals with AD with 1 direction or idea (i.e., proposition) at a time, closed-ended questions, and paraphrased repetition. Caregivers also frequently used encouraging comments and the resident's name during the task; however, use of these strategies was not correlated to task success rate.

CONCLUSION

This study adds to the limited body of evidence supporting the use of specific communication strategies by caregivers assisting individuals with moderate to severe AD during successful completion of ADLs.

Humour, irony and sarcasm in severe Alzheimer's dementia – a corrective to retrogenesis?

Retrogenesis is claimed to be the process by which degenerating mechanisms in the brain, as found in Alzheimer's disease (AD), reverse the order of acquisition of functions, including language, in normal child development. In FAST (Functional Assessment Staging of Alzheimer's disease) stages of AD are translated into corresponding developmental ages. Humour, irony and sarcasm are communicative strategies linked to meta-linguistic abilities developed late in childhood. If found in the conversation of people with moderately severe AD according to FAST, this could be an indication of problems in the FAST scale and subsequently in the concept of retrogenesis concerning speech and language abilities. Comprehensive, open-ended, naturalistic conversations between three nursing home residents with moderately severe AD according to FAST and their professional care-givers were analysed with concepts developed in linguistics as to the occurrence of humour, irony and sarcasm. Although the data material was limited, the findings indicate an unexpected communicative competence of the three participants. This is a corrective to retrogenesis and a caveat for poor expectations of intelligible conversations with demented people for professionals and the people they advise. Implications for research strategies and for the general knowledge of communicative competence in AD are addressed in the discussion section, and possible ways of elucidating deterioration of speech and language abilities in AD are suggested.

Alzheimer's disease-associated disability: An ICF approach

PURPOSE

The aim of the study is to provide a description of dementia-associated disability in Alzheimer's disease (AD) patients through the International Classification of Functioning, Disability and Health (ICF).

METHOD

Twenty-six AD patients at different stages of disease participated in the study. Mini Mental State Examination (MMSE) and Global Deterioration Scale (GDS) were used to stage the degree of cognitive impairment and the stage of disease, respectively. All subjects were classified using the ICF categories in the more detailed four-level version. Correlation between compromised ICF items and both MMSE and GDS scores were calculated through Spearman Rho test.

RESULTS

Mental functions were impaired in all the subjects examined. Data on activity and participation showed that not only domestic life, self care, and mobility but also communication and interaction and social relationships are compromised in AD patients. Three main areas appeared as the most relevant facilitators: products and technology, support and relationship and services, systems and policies. ICF codes were generally correlated with both MMSE and GDS: subjects who appeared more compromised on MMSE and GDS showed higher impairment of functions, activity limitation, and participation restriction.Conclusion. ICF is a useful tool to describe health status in AD patients in that it underlines important aspects of daily living generally not considered by activity of daily living scales such as communication, social relationships, and recreation and leisure.

Analysis of brief language tests in the detection of cognitive decline and dementia

Lexical access difficulties are frequent in normal aging and initial stages of dementia.Verbal fluency tests are valuable to detect cognitive decline, evidencing lexico-semantic and executive dysfunction.

Depressive symptoms in Alzheimer's disease: natural course and temporal relation to function and cognitive status

OBJECTIVES

To examine the natural course of depressive symptoms in patients with probable Alzheimer's disease (AD), specifically, the temporal relationship between depressive symptoms, function, and cognitive status.

DESIGN

Multicenter cohort study with follow-up of up to 14 years.

SETTING

Patients from the two Multicenter Study of Predictors of Disease Course in Alzheimer's Disease (Predictors Study) cohorts were recruited at five sites in the United States and Europe.

PARTICIPANTS

Patients diagnosed with probable AD (n=536) enrolled in a longitudinal study (Predictors Study).

MEASUREMENTS

Depressive symptoms were evaluated at 6-month intervals using the Columbia Scale for Psychopathology in Alzheimer's Disease. The Modified Mini-Mental State (3MS) and Blessed Dementia Rating Scale (BDRS) were used to assess cognitive status and functional activity, respectively.

RESULTS

The prevalence of depressive symptoms was stable over the first 3 years of follow-up, at approximately 40%. There was a significant drop to 28% and 24% in the fourth and fifth years of follow-up, respectively. Time-dependent Cox analysis revealed that functional activity (BDRS) but not cognitive status (3MS) was a significant predictor of the first episode of depressive symptoms during follow-up. Generalized estimating equation analyses showed that AD duration and functional activity but not cognitive status were significantly related to depressive symptoms over the entire follow-up period.

CONCLUSION

Depressive symptoms are common in AD, but their prevalence decreases over time. Examination of the temporal relationship between depressive symptoms and risk factors suggests that decline in function but not in cognition precedes the first episode of depressive symptoms in patients with probable AD.

Effects of working memory deficits on the communicative functioning of Alzheimer's dementia patients

Individuals with Alzheimer's disease experience frontal lobe pathology and deficits in working memory processes are well documented. Less documented is how various working memory deficits impact communicative functioning. The performance data of individuals with mild and moderate Alzheimer's dementia on five tests of language comprehension and four tests of language expression are presented and discussed in the context of possible contributions from impaired working memory functions. The argument is advanced that diminished scores on tests of language comprehension and production result primarily from attenuated span capacity, difficulty focusing attention, encoding, and activation of long-term knowledge rather than from loss of linguistic knowledge. Techniques that may advantage Alzheimer's patients in the comprehension and expression of linguistic information are discussed.(1) Readers will become familiar with the typical functioning of individuals with Alzheimer's disease on common linguistic expression and comprehension tasks. (2) Readers will become familiar with the distinction between language knowledge and performance and its importance in understanding the cause of communication breakdowns in individuals with Alzheimer's disease. (3) Readers will become familiar with techniques that may facilitate the communicative functioning of individuals with Alzheimer's disease.