Dementia: diagnostics, early treatment, and assistance from family members

White matter lesions and soluble interleukin-1 receptor type II in CSF from demented and non-demented subjects

White matter lesions (WMLs) in the brain is a common, unspecific finding on magnetic resonance imaging appearing both in the healthy elderly as well as in a number of different diseases including dementia disorders. However, the pathophysiological and clinical significance of WMLs in dementia disorders is still unknown. In this study, we investigated the possibility of their origin being inflammatory by studying the correlation between WMLs and cerebrospinal fluid (CSF) levels of the proinflammatory cytokine soluble interleukin-1 receptor type II (sIL-1RII). The sIL-1RII is a member of the IL-1 family, and has been found to be elevated in CSF from Alzheimer's disease (AD) patients. In the present study, two groups of patients complaining of memory disturbances with little or extensive WMLs respectively, were examined, as well as healthy subjects. In accordance with other reports, WML scores (total, periventricular as well as deep lesions) were positively correlated with age but not mini mental state examination (MMSE) scores, and were significantly higher in patients with a dementia diagnosis as compared to non-demented subjects. There were no differences in sIL-1RII levels in CSF regardless of amount of total, periventricular or deep WMLs, nor were there any differences between demented and non-demented subjects. In conclusion, sIL-1RII levels in CSF are not correlated to magnetic resonance imaging WMLs in patients with dementia disorders or in healthy subjects.

Staff opinions about the leadership and organisation of municipal dementia care

The present study describes the opinions of experienced staff providing direct care to patients with dementia in municipal units in Sweden. The focus is mainly on leadership and other organisational factors. A purposeful sample of 31 staff members employed in municipal dementia care in both urban and rural areas in mid-Sweden were selected. Data were collected within a qualitative paradigm using semi-structured interviews which were tape-recorded and analysed using a modified phenomenographical approach. The nearly unanimous opinions of the interviewees indicated that there was a great lack of daily leadership in the units. Thus, few units had clearly formulated goals and few had regular care planning for their residents. Poorly developed teamwork was reported in the care of people with dementia especially regarding doctors, whose visits to the unit were too infrequent and too short, and did not include a direct exchange of information with other staff. In addition, little or no staff education and guidance/supervision was provided on a regular basis. In conclusion, without any unreasonable increase in cost, measures such as introducing clear leadership at the care unit level, concentrating on multi-professional teamwork, and providing education and guidance/supervision to the staff would probably result in better care for patients with dementia and their families.

Magnetic resonance imaging in dementia. A study of brain white matter changes

Non-specific white matter changes (WMC) in the brain are common findings in the elderly population. Although they are frequently seen in non-demented persons, WMC seem to be more common in demented patients. The significance of these changes, as well as their pathophysiological background, is incompletely understood. The aim of this thesis was to study different aspects of WMC using MR imaging (MRI) and to investigate the clinical significance of such changes in subjects with mild cognitive impairment or dementia. In study I post-mortem MRI of the brain was compared to corresponding neuropathology slices. WMC were quantified and found to be more extensive on neuropathology. The areas that appeared normal on MRI but not on histopathology represented only minor changes with increased distance between the myelinated fibres but with preserved axonal network and glial cell density. Study II evaluated the blood-brain barrier (BBB) integrity to investigate if an increased permeability could be shown in WMC. A contrast-enhanced MRI technique was used to detect small degrees of enhancement. No general increase in BBB could be detected in the WMC areas. In study III the relation between WMC and apolipoprotein E (APOE) genotype was explored in patients with Alzheimer's disease (AD). Results showed that AD patients, who were homozygous for the APOE epsilon 4 allele had more WMC than patients with other genotypes. This was most significant for changes in the deep white matter. Results also indicated that in AD patients carrying the epsilon 4 allele, WMC are not age-related phenomena, but might be related to the aetiology of the disease. Study IV aimed to investigate if WMC in a specific brain region affect cognitive functions related to that area. Periventricular WMC in the left frontal lobe predicted a decrease in initial word fluency, a test though to reflect left frontal lobe functioning. This indicates that WMC might have specific effects in different brain regions. In study V we evaluated the prognostic significance of WMC in patients with memory impairment, regarding the rate of further global cognitive decline. There was no difference in outcome between patients having extensive WMC and a matched control group, during 2-4 years of follow up, and assessed by the "Mini-Mental State Examination". In conclusion, this work has shown and characterised pathological changes in the white matter not visible on conventional MRI. We have also shown that there is no major general increase in BBB permeability in areas of WMC. In addition, homozygosity with regard to the APOE epsilon 4 gene allele implies an increased extent of WMC in AD patients. In AD patients carrying this gene allele, WMC are not merely age-related phenomena, but might be related to the aetiology of the disease. We also claim that WMC in a specific location might impair cognitive functions that rely on those specific pathways. In contrast, WMC do not seem to have any prognostic value in predicting the rate of global cognitive decline in patients at a memory clinic.

[Family caregivers of people with neurodegenerative disease: profile, contributions, and impact of care]

OBJECTIVE

To analyse the informal system of caring for people with neuro-degenerative disease: what it consists of and the characteristics of main carers, the type of care given, and the consequences for the main carer of assuming these functions.

DESIGN

Descriptive cross-sectional study conducted by means of a home-filled questionnaire.

SETTING

Autonomous Community of Andalusia.

PARTICIPANTS

72 main carers of someone with neuro-degenerative disease, chosen from a sub-sample of 1000 homes in which at least one dependent person lives and receives care from a member of his/her family or social network with whom he/she resides. This sub-sample was based on a random sample of 3160 Andalusian homes stratified proportionately according to province and size of dwelling.

MAIN RESULTS

In 86.1% of the 72 homes polled, health care was provided only by the informal system network. In over half the homes, care was provided by just one person, the main carer. The main carer was usually a woman (87.4%), with an average age of 54.52, house-wife and close family member of the sick person. In our study the beneficiaries of care had an average age of 77.63, a low level of autonomy in daily activities, and had had a neuro-degenerative disease for an average of 8.16 years. The main kinds of care provided in the home for people with neuro-degenerative disease were help in instrumental activities, care related to daily activities, observation/company and supervision of medicines. Main carers believed that undertaking this work had seriously affected their health (72.2%), the use they made of their time (84.7%), their social life (83.3%) and their economic position (44.4%).

CONCLUSIONS

People with neuro-degenerative disease make considerable demands on health care provision, which is mainly covered at home by the immediate family network. In most cases this network consists of just one person, the main carer, on whom falls the entire burden of care. The assumption of this role directly affects the health of a large number of carers, as well as other areas of their lives, in particular the possibility of conducting a social life and using their time for themselves or for activities other than caring.

A mitochondrial tRNA(Val) gene mutation (G1642A) in a patient with mitochondrial myopathy, lactic acidosis, and stroke-like episodes

We studied a patient with the diagnosis of mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) for mitochondrial DNA mutations in muscle. Established MELAS mutations were excluded. Mitochondrial DNA was further analyzed for mutations in the 22 tRNA genes by single-strand conformation polymorphism (SSCP) analysis; a tRNA(Val) mutation (G1642A) was found. The structure of the altered tRNA, the heteroplasmy, and the absence of the mutation in the mother and in 100 control subjects suggests that the tRNA(Val) mutation is associated with the MELAS syndrome.