Prevalence of dementia in Chinese elderly in Hong Kong

Late-life longitudinal blood pressure trajectories as predictor of dementia

While hypertension is widely recognized as a risk factor for dementia, few observational studies and clinical trials fully accounted for the effect of age on blood pressure (BP) changes prior to dementia onset. In this territory-wide population-based longitudinal study of 16,591 community-living dementia-free older adults, we followed their BP and cognitive status and tested if loss of longitudinal increase in BP in late life was associated with higher dementia risk in 6 years, with consideration of the confounding effects of hypertension, hypotension, BP variability, and other health problems and behaviours and, in the data analysis, exclusion of individuals who developed dementia within 3 years after baseline to minimize risk of reverse causality. Over 72,997 person-years of follow-up, 1429 participants developed dementia. We found that loss of longitudinal increase in systolic BP (defined as SBP increased by either < 10 mmHg or 10%) from baseline to Year 3 was independently associated with higher risk of incident dementia at Years 4 to 6 (adjusted OR 1.22, 95% CI 1.02-1.45, p = 0.03; adjusted OR 1.24, 95% CI 1.03-1.50, p = 0.02; respectively). Our findings suggest that late-life SBP trajectory changes might independently predict dementia onset and highlight the importance of including longitudinal BP monitoring in dementia risk assessment.

Demographics and Medication Use of Patients with Late-Onset Alzheimer's Disease in Hong Kong

BACKGROUND

Alzheimer's disease (AD) is the most common cause of dementia in the elderly population. However, epidemiological studies on the demographics of AD in Hong Kong population are lacking.

OBJECTIVE

We investigated the demographics, comorbidities, mortality rates, and medication use of patients with AD in Hong Kong to understand how the disease has been managed locally.

METHODS

This was a collaborative study of The Hong Kong University of Science and Technology and the Hospital Authority Data Collaboration Lab. We analyzed the demographic data, clinical records, diagnoses, and medication records of patients with AD under the care of the Hospital Authority between January 1, 2007 and December 31, 2017.

RESULTS

We identified 23,467 patients diagnosed with AD. The median age at diagnosis was 84 years old, and 71% of patients were female. The most common comorbidity was hypertension (52.6%). 39.9% of patients received medications for dementia; of those, 68.4% had taken those medications for > 1 year. Compared to nonusers, long-term AD medication users had a significantly younger age of AD onset and were taking more lipid-regulating medication, diabetes medication, or antidepressants. Surprisingly, the use of antipsychotics in patients with AD was quite common; 50.7% of patients had received any type of antipsychotic during disease progression.

CONCLUSION

This study provides detailed information on the demographics and medication use of patients with AD in Hong Kong. The data from this AD cohort will aid our future research aiming to identify potential AD risk factors and associations between AD and other diseases.

Is Tai Chi an effective intervention for enhancing health-related quality of life in older people with mild cognitive impairment? An interventional study

BACKGROUND

Many neuropsychiatric symptoms in persons of MCI cause negative impacts on their HRQOL. There is limited HRQOL research investigating the effect of Tai Chi on older people with MCI.

OBJECTIVE

To determine the effectiveness of a Tai Chi program in enhancing health-related quality of life (HRQOL) among community-dwelling older people with mild cognitive impairment (MCI) in Hong Kong.

METHODS

This was a quasi-experimental study using a nonequivalent control group (CG) design. Four social centres for older people participated in the study, of which two centres were randomised for Tai Chi intervention and the other two were treated as control. Participants in the intervention group (IG) were arranged for a 1-hour Tai Chi class twice weekly for 16 weeks, whereas participants in the CG were advised to join various recreational activities in the social centres as usual. For outcome evaluation, the Chinese version of the Short Form-12 Health Survey-Standard 1 (SF-12) was employed to assess participants' perceived HRQOL.

RESULTS

One hundred and sixty participants were recruited (IG = 80, CG = 80). Data were collected at baseline (T0) and 16-week post-intervention (T1).The IG reported significant improvement in the physical health component (PCS) (p = .036), the mental health component (MCS) (p = .014), as well as several subscales of SF-12, namely, the role-physical (RP) (p = .044), the bodily pain (BP) (p < .001) and the vitality (VT) (p = .004) subscales, in comparison with the CG.

CONCLUSION

The current study results extended our knowledge about Tai Chi of which the mind-body exercise could enhance the physical and psychosocial well-being in older people with MCI.

IMPLICATIONS FOR PRACTICE

The findings have the potential to inform health and social care professionals to promote Tai Chi in community settings, as it may represent a non-intensive and age-fitting strategy to promote HRQOL in older people with MCI.

TRIAL REGISTRATION

NCT03404765 (Retrospectively registered January 19, 2018).

Risk of incident dementia varies with different onset and courses of depression

BACKGROUND

This study aims to examine if risk of dementia differs between adult- and late-onset depression.

METHODS

16,608 community-living dementia-free older adults were followed for 6 years to the outcome of incident dementia. Depression was diagnosed according to international diagnostic guidelines. Depression in adulthood or late life was categorized using age 65 as cutoff. Hazard ratio for dementia was estimated using Cox regression analysis.

RESULTS

People with depression in adulthood only did not have higher dementia incidence, suggesting those in remission from adult-onset depression are not at greater risk of dementia. Conversely, having depression in both adulthood and late life was associated with higher dementia risk, and improvement in depression in late life was associated with lower risk, suggesting persistent or recurrent lifetime depression is a risk factor for dementia. Those with depression in late life only were not associated with higher dementia risk after controlling for the longitudinal changes in depressive symptoms, consistent with late-onset depression being a prodrome of dementia.

LIMITATIONS

Reverse causation is a potential limitation. This was minimized by careful ascertainment of depression and dementia cases, exclusion of individuals with suspected dementia at baseline and those who developed dementia within 3 years after baseline, and controlling for various important confounders.

CONCLUSIONS

Risk of incident dementia varies with presence and resolution of depression at different ages. Further studies are needed to test whether treating adult-onset depression may prevent dementia. Older adults with a history of depression present for an extended time should be monitored for cognitive decline.

Preventing dementia? Interventional approaches in mild cognitive impairment

Mild cognitive impairment (MCI) is defined as an intermediate state between normal cognitive aging and dementia. It describes a status of the subjective impression of cognitive decline and objectively detectible memory impairment beyond normal age-related changes. Activities of daily living are not affected. As the population ages, there is a growing need for early, proactive programs that can delay the consequences of dementia and improve the well-being of people with MCI and their caregivers. Various forms and approaches of intervention for older people with MCI have been suggested to delay cognitive decline. Pharmacological as well as non-pharmacological approaches (cognitive, physiological, nutritional supplementation, electric stimulation, psychosocial therapeutic) and multicomponent interventions have been proposed. Interventional approaches in MCI from 2009 to April 2019 concerning the cognitive performance are presented in this review.

Neuropsychiatric Symptoms and Risk Factors in Mild Cognitive Impairment: A Cohort Investigation of Elderly Patients

BACKGROUND

Neuropsychiatric symptoms (NPS) have been shown to affect the progression and development of Alzheimer's disease (AD) in the elderly. However, the published data are still controversial and limited in large cohort-based NPS study.

AIM

To explore the potential relationship between NPS and mild cognitive impairment (MCI) among the elderly of Chinese community.

METHODS

A total of 465 Chinese community-dwelling elderly (age ≥ 60 years) with mild cognitive impairment (MCI) were recruited into this investigation. At baseline, enrolled participants were assessed for Clinical Dementia Rating (CDR), mini-psychiatric examination. They were also subjected to categorical language fluency test, list learning and delayed recall. We assessed the NPS severity by Neuropsychological Inventory (NPI). The global cognitive status (GCS) of the participants at the end of the 3-year study period were measured with the CDR.

RESULTS

Approximately 41.6% of subjects had 1 or more NPS (total NPI score ≥ 1) at baseline. The most common NPSs were nocturnal behavior (20.8%), depression (17.3%), apathy (12.7%) and anxiety (13.2%). At the end of 3-year follow-up, 26.9% of baseline depressed patients developed AD, while 15.2% of baseline non-depressed patients developed AD (χ2 = 4.86, P=0. 04). Abnormal motor behavior was significantly correlated with cognitive deterioration as well (χ2 = 5.75, P=0. 03). Logistic regression analysis revealed that depression was considered as a risk factor for AD progression at baseline (95% CI: 1.12-5.67, OR=2.37, P=0.03).

CONCLUSIONS

Depression may be an independent factor representing early neurodegeneration in elder patients with MCI. Further studies are warranted to assess whether effective management of NPS promotes the cognitive functions.

Older residents' perceptions of family involvement in residential care

AIM

This study explored the Chinese older people's perceptions regarding family involvement and specific factors influencing family involvement in residential care homes.

BACKGROUND

Family involvement in residential care home is a multi-dimensional construct that connects the resident with their family, friends, neighbours and care professionals to facilitate their physical, psycho-emotional and social well-being. However, it remains unclear as to what Chinese residents perceive as the meaning of involving the family and components of it that are important to later live.

MATERIAL AND METHODS

A descriptive qualitative study using semi-structured interviews was conducted in two residential care homes in Macao. Ten Chinese residents were purposively sampled. The interview data were taped-recorded and transcribed. Fieldnotes and visitors' records were collected. The data were content-analyzed.

RESULTS

Chinese residents' perceptions of family involvement were captured by four themes: components of family involvement, factors influencing family involvement, impacts of family involvement on residents' lives, and promoting family involvement strategies.

CONCLUSION

Findings provided insights for geriatric care providers to acknowledge the contributions that family members can make to be more involved in the residents' live, and to strengthen relationships. Family involvement can also help to facilitate sense of blessing and feelings of achievements for the residents.

A randomized placebo-controlled trial of using B vitamins to prevent cognitive decline in older mild cognitive impairment patients

BACKGROUND & AIMS

Mild cognitive impairment (MCI) patients are at risk of cognitive decline, while elevated serum homocysteine is also associated with cognitive impairment. Thus, older people with MCI and hyperhomocysteinemia may be under greater risk of cognitive decline. We therefore performed a randomized trial of homocysteine-lowering by B vitamins supplementation to prevent cognitive decline in older MCI patients with elevated serum homocysteine.

METHODS

279 MCI outpatients aged ≥65 years with serum homocysteine ≥10.0 μmol/L were randomly assigned to take either methylcobalamin 500 μg and folic acid 400 μg once daily, or two placebo tablets for 24 months. All subjects were followed up at 12 monthly intervals. The primary outcome was cognitive decline as defined by an increase in clinical dementia rating scale (CDR) sum of boxes (CDR_SOB). The secondary outcomes were global CDR, memory Z score, executive function Z score and Hamilton depression rating scale (HDRS) score.

RESULTS

The clinical characteristics between two groups were well matched, except that the supplement group had better executive function. The supplement effectively lowered serum homocysteine (mean 13.9 ± sd 3.5 μmol at baseline to 9.3 ± 2.4 μmol/L at month 24). At month 24, there was no significant group difference in CDR_SOB or any secondary outcomes (mean changes in CDR_SOB 0.36 versus 0.22 in supplement and placebo groups respectively). At month 12, the supplement group significantly improved in executive function and had lower HDRS score (P = 0.004 and 0.012 respectively). Group difference was significant for HDRS, but borderline significant for executive function. (P = 0.01; 0.06 respectively) These effects were not significant at month 24. Subgroup analysis showed that aspirin use had significant interaction with B supplements in CDR_SOB at month 24 (Beta 0.189, P = 0.005).

CONCLUSIONS

Vitamin B₁₂ and folic acid supplementation did not reduce cognitive decline in older people with MCI and elevated serum homocysteine, though the cognitive decline over two years in placebo group was small. The supplement led to a significant reduction in depressive symptoms at month 12, though this effect was not sustained. Aspirin use had a negative interaction effect on cognitive functioning with B supplements.

CLINICAL TRIAL REGISTRATION

Centre for Clinical Research and Biostatistics (CCRB) Clinical Trials Registry: CUHK_CCT00373.

Higher dementia incidence in older adults with type 2 diabetes and large reduction in HbA1c

BACKGROUND

although type 2 diabetes increases risk of dementia by 2-fold, whether optimizing glycemic level in late life can reduce risk of dementia remains uncertain. We examined if achieving the glycemic goal recommended by the American Diabetes Association (ADA) within a year was associated with lower risk of dementia in 6 years.

METHODS

in this population-based observational study, we examined 2246 community-living dementia-free Chinese older adults with type 2 diabetes who attended the Elderly Health Centres in Hong Kong at baseline and followed their HbA1c level and cognitive status for 6 years. In line with the ADA recommendation, we defined the glycemic goal as HbA1c < 7.5%. The study outcome was incident dementia in 6 years, diagnosed according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) or Clinical Dementia Rating of 1-3.

RESULTS

those with HbA1c ≥ 7.5% at baseline and HbA1c < 7.5% in 1 year were associated with higher rather than lower incidence of dementia, independent of severe hypoglycemia, glycemic variability and other health factors. Sensitivity analyses showed that a relative reduction of ≥10%, but not 5-10%, in HbA1c within a year was associated with higher incidence of dementia in those with high (≥8%) and moderate (6.5-7.9%) HbA1c at baseline.

CONCLUSION

a large reduction in HbA1c could be a potential predictor and possibly a risk factor for dementia in older adults with type 2 diabetes. Our findings suggest that optimizing or intensifying glycemic control in this population requires caution.

Peak width of skeletonized mean diffusivity and its association with age-related cognitive alterations and vascular risk factors

Introduction

Only two studies investigated the associations between peak width of skeletonized mean diffusivity (PSMD) and age-related cognitive alterations, whereas none of the studies investigated the association with vascular risk factors.

Methods

We evaluated 801 stroke- and dementia-free elderlies with baseline and 3-year follow-up assessments. Regression analyses were used to assess the association between age-related cognitive functions and PSMD. Simple mediation models were used to study the mediation effect of PSMD between vascular risk factors and age-related cognitive outcomes.

Results

PSMD was negatively associated with processing speed at baseline and negatively associated with processing and memory scores at 3-year follow-up. The association between vascular risk factors and age-related cognition was mediated by PSMD, as well as other diffusion tensor imaging markers.

Discussion

PSMD is preferred over other diffusion tensor imaging markers as it is sensitive to age-related cognitive alterations and calculation is fully automated. PSMD is proposed as a research tool to monitor age-related cognitive alterations.

Loneliness, Depressive Symptoms, and Cognitive Functioning Among U.S. Chinese Older Adults

Objective: Loneliness has been associated with cognitive functioning in the general older adult population. Previous studies further indicate that loneliness has a strong association with depressive symptoms and the two constructs can reinforce each other to diminish well-being. However, such relationships have not been examined in U.S. Chinese older adults. This study attempts to bridge this knowledge gap. Method: Data were drawn from a population-based study of 3,159 U.S. Chinese older adults in the Greater Chicago area. Stepwise multivariate regression analyses were conducted to examine the relationship between loneliness, depressive symptoms, and global cognitive functioning. Results: Loneliness was associated with poor global cognitive functioning in U.S. Chinese older adults, though the relationship became nonsignificant after adjustment for depressive symptoms. The interaction term between loneliness and cognitive functioning was statistically significant (p < .01). The findings further highlight the importance of age, education, number of children, number of people in household, and length of residence in the U.S. in cognitive functioning among U.S. Chinese older adults. Discussion: The study findings indicate that loneliness and depressive symptoms act together to influence cognitive functioning in U.S. Chinese older adults. Research and clinical implications of the findings are discussed.

The use of smartphones for wayfinding by people with mild dementia

The aim of this study was to explore the acceptability, feasibility and usability of older people with mild dementia to use smartphone for wayfinding. Thirty cognitively normal older people and 16 people with mild dementia were recruited to participate in a wayfinding trial in the free-living environment. Five feasibility and three acceptability markers were compared between the groups. Content analysis on the video-recorded trial processes and individual interviews was employed to identify the usability issues. The results found that there were no significant between-group differences on the feasibility markers, except that the people with mild dementia needed significantly more time to complete the wayfinding trial and workshop; or on the acceptability items. Sensory/cognitive impairment and GPS signal reliability affected their usability. Mild dementia does not limit the older people to use smartphones for wayfinding in the free-living environment. Future studies should examine the efficacy and safety of smartphone to promote outdoor independence of the people with mild dementia.

Association of Daily Intellectual Activities With Lower Risk of Incident Dementia Among Older Chinese Adults

IMPORTANCE

Associations between late-life participation in intellectual activities and decreased odds of developing dementia have been reported. However, reverse causality and confounding effects due to other health behaviors or problems have not been adequately addressed.

OBJECTIVE

To examine whether late-life participation in intellectual activities is associated with a lower risk of incident dementia years later, independent of other lifestyle and health-related factors.

DESIGN, SETTING, AND PARTICIPANTS

A longitudinal observational study was conducted at all Elderly Health Centres of the Department of Health of the Government of Hong Kong among 15 582 community-living Chinese individuals age 65 years or older at baseline who were free of dementia, with baseline evaluations performed January 1 to June 30, 2005, and follow-up assessments performed from January 1, 2006, to December 31, 2012. Statistical analysis was performed from January 1, 2015, to December 31, 2016.

MAIN OUTCOMES AND MEASURES

The main outcome was incident dementia as diagnosed by geriatric psychiatrists in accordance with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, or a Clinical Dementia Rating of 1 to 3. At baseline and follow-up interviews, self-reported information on participation in intellectual activities within 1 month before assessment was collected. Examples of intellectual activities, which were described by a local validated classification system, were reading books, newspapers, or magazines; playing board games, Mahjong, or card games; and betting on horse racing. Other important variables including demographics (age, sex, and educational level), physical and psychiatric comorbidities (cardiovascular risks, depression, visual and hearing impairments, and poor mobility), and lifestyle factors (physical exercise, adequate fruit and vegetable intake, smoking, and recreational and social activities) were also assessed.

RESULTS

Of the 15 582 individuals in the study, 9950 (63.9%) were women, and the median age at baseline was 74 years (interquartile range, 71-77 years). A total of 1349 individuals (8.7%) developed dementia during a median follow-up period of 5.0 years. Multivariable logistic regression analysis showed that the estimated odds ratio for incident dementia was 0.71 (95% CI, 0.60-0.84; P < .001) for those with intellectual activities at baseline, after excluding those who developed dementia within 3 years after baseline and adjusting for health behaviors, physical and psychiatric comorbidities, and sociodemographic factors.

CONCLUSIONS AND RELEVANCE

Active participation in intellectual activities, even in late life, might help delay or prevent dementia in older adults.

Effects of tai chi on cognition and instrumental activities of daily living in community dwelling older people with mild cognitive impairment

Background

Cognitive impairment places older adults at high risk of functional disability in their daily-life activities, and thus affecting their quality of life. This study aimed to examine the effects of Tai Chi on general cognitive functions and instrumental activities of daily living (IADL) in community-dwelling older people with mild cognitive impairment (MCI) in Hong Kong.

Methods

The study adopted a multi-site nonequivalent control-group pretest-posttest design. 160 community-dwelling older people, aged ≥60, with MCI, from four community elderly centers participated in the study. The intervention group (IG, n = 80) received training in the Yang-style simple form of Tai Chi, at a frequency of two lessons per week for 16 weeks. Each lesson lasted for one hour. The control group (CG, n = 80) had no treatment regime and joined different recreational activity groups in community centers as usual within the study period. Outcome measures included measures of global cognitive status and IADL. The Chinese version of the Mini-Mental State Examination (CMMSE) was used for global cognitive assessment. The Hong Kong Chinese version of Lawton’s Instrumental Activities of Daily Living (IADL-CV) was used to assess the participants’ IADL levels. General Estimating Equations (GEE) was used to examine each of the outcome variables for the two groups at the two study time points (the baseline and at the end of the study). Meanwhile, minimum detectable change (MDC) was calculated to estimate the magnitude of changes required to eradicate the possibility of measurement error of outcome measures.

Results

Seventy four participants in the IG and 71 participants in the CG completed the study. With adjustments for differences in age, education, marital status and living conditions, the findings revealed that the participants in the IG scored significantly better on the CMMSE test (P = 0.001), and the instrumental ADL questionnaire (P = 0.004). However, those scores changes did not exceed the limits of the respective MDCs in the study, the possibility of measurement variation due to error could not be excluded.

Conclusion

Tai Chi may be an effective strategy to enhance cognitive health and maintain functional abilities in instrumental ADL in older people with MCI.

Trial registration

NCT03404765 (Retrospectively registered January 19, 2018)

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0720-8) contains supplementary material, which is available to authorized users.

Asymmetry of Hippocampus and Amygdala Defect in Subjective Cognitive Decline Among the Community Dwelling Chinese

Background: Subjective cognitive decline (SCD) may be the first clinical sign of Alzheimer's disease (AD). SCD individuals with normal cognition may already have significant medial temporal lobe atrophy. However, few studies have been devoted to exploring the alteration of left-right asymmetry with hippocampus and amygdala in SCD. The aim of this study was to compare SCD individuals with amnestic mild cognitive impairment (MCI) patients and the normal population for volume and asymmetry of hippocampus, amygdala and temporal horn, and to assess their relationship with cognitive function in elderly population living in China. Methods: 111 SCD, 30 MCI, and 67 healthy controls (HC) underwent a standard T1-weighted MRI, from which the volumes of the hippocampus and amygdala were calculated and compared. Then we evaluated the pattern and extent of asymmetry in hippocampus and amygdala of these samples. Furthermore, we also investigated the relationship between the altered brain regions and cognitive function. Results: Among the three groups, SCD showed more depressive symptoms (p < 0.001) and higher percentage of heart disease (16.4% vs. 35.1%, p = 0.007) than controls. In terms of brain data, significant differences were found in the volume and asymmetry of both hippocampus and amygdala among the three groups (P < 0.05). In logistic analysis controlled by age, gender, education level, depression symptoms, anxiety symptom, somatic disease and lifestyle in terms of smoking, both SCD and MCI individuals showed significant decreased right hippocampal and amygdala volume than controls. For asymmetry pattern, a ladder-shaped difference of left-larger-than-right asymmetry was found in amygdala with MCI>SCD>HC, and an opposite asymmetry of left-less-than-right pattern was found with HC>SCD>MCI in hippocampus. Furthermore, correlation was shown between the volume of right hippocampus and right amygdala with MMSE and MoCA in SCD group. Conclusion: Our results supported that SCD individuals are biologically distinguishable from HC, and this may relate to cognitive impairment, although more longitudinal studies are need to investigate this further.Moreover, different levels of asymmetry in hippocampus and amygdala might be a potential dividing factor to differentiate clinical diagnosis.

Lower risk of incident dementia among Chinese older adults having three servings of vegetables and two servings of fruits a day

Background

dietary modification can potentially reduce dementia risk, but the importance of fruits and the amount of vegetables and fruits required for cognitive maintenance are uncertain. We examined whether the minimal daily requirement of vegetables and fruits recommended by the World Health Organization (WHO) would independently lower dementia risk.

Methods

in this population-based observational study, we examined the diet of 17,700 community-living dementia-free Chinese older adults who attended the Elderly Health Centres in Hong Kong at baseline and followed their cognitive status for 6 years. In line with the WHO recommendation, we defined the cutoff for minimal intake of vegetables and fruits as at least three and two servings per day, respectively. The study outcome was incident dementia in 6 years. Dementia was defined by presence of clinical dementia in accordance with the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) or Clinical Dementia Rating of 1-3.

Results

multivariable logistic regression analysis showed that the estimated odds ratios for incident dementia were 0.88 (95% confidence interval 0.73-1.06; P = 0.17) for those consuming at least three servings of vegetables per day, 0.86 (0.74-0.99; P < 0.05) for those consuming at least two servings of fruits per day and 0.75 (0.60-0.95; P = 0.02) for those consuming at least these amounts of both at baseline, after adjusting for age, gender, education, major chronic diseases, physical exercise and smoking.

Conclusion

having at least three servings of vegetables and two servings of fruits daily might help prevent dementia in older adults.

The clinical utility, reliability and validity of the Rivermead Behavioural Memory Test-Third Edition (RBMT-3) in Hong Kong older adults with or without cognitive impairments

This study examined the use of the Hong Kong version of the Rivermead Behavioral Memory Test-Third Edition (RBMT-3) for older adults, and by presenting the optimal cut-off scores for patients with cognitive impairments, and for a group of peers who have functional everyday cognition. Hundred older adults residing in community dwellings were recruited from three non-government organisations and completed the RBMT-3: 29 patients with mild to moderate dementia, 34 persons at risk for MCI, and 37 matched older adults with everyday functional cognition for a healthy control group (NC). The test has excellent inter-rater (ICC [2, 1] = 0.997), intra-rater (ICC [3, 1] = 0), and parallel version (ICC [3, 1] = 0.990) reliabilities, as well as satisfactory internal consistency (Cronbach's alpha: 0.643-0.832). The scores of the MCI group were significantly lower than those of NC group in four subtests. The optimal cut-off scaled scores of ≤ 41.5, ≤ 102.5, and ≤ 131.5 are suggested for the RBMT-3 to discriminate between patients with mild and moderate dementia, mild dementia and MCI, and MCI and NC, with sensitivities 73%, 100% and 94.1%, respectively. This version is useful to differentiate those with or without risk of cognitive impairments.

A randomized placebo controlled trial of vitamin B12 supplementation to prevent cognitive decline in older diabetic people with borderline low serum vitamin B12

BACKGROUND & AIMS

Older diabetic people are at risk of cognitive decline. Vitamin B₁₂ deficiency in older people is associated with cognitive impairment and Alzheimer's disease. Vitamin B₁₂ deficiency may therefore contribute to cognitive decline in older diabetic people. We therefore performed a randomized placebo-controlled trial of vitamin B₁₂ supplementation to prevent cognitive decline in older diabetic people with mild vitamin B₁₂ deficiency.

METHODS

271 diabetic non-demented outpatients aged 70 years or older with plasma vitamin B₁₂ 150-300 pmol/L in outpatient clinics were randomly assigned to take either methylcobalamin 1000 μg or two similar looking placebo tablets once daily for 27 months. All subjects were followed up at 9 monthly intervals. The primary outcome is cognitive decline as defined by an increase in clinical dementia rating scale (CDR) global score. The secondary outcomes included Neuropsychological Test Battery (NTB) z-scores, serum methymalonic acid (MMA) and homocysteine.

RESULTS

The subjects in the trial groups were well matched in clinical characteristics, except that active intervention group had more smokers. 46.5% and 74.1% had elevated serum methymalonic acid (≥0.21 μmol/L) and homocysteine (≥13 μmol/L) respectively. 44% of the subjects had CDR score of 0.5 suggesting questionable dementia. At month 9 and 27, serum MMA and homocysteine was significantly reduced in the active treatment group, when compared with placebo group. (P < 0.0001, student t test) At month 27, there was no significant group difference in changes in CDR or NTB z-scores. Exclusion of smokers did not alter the results. Subgroup analysis of high MMSE and serum MMA showed similar results.

CONCLUSION

Vitamin B₁₂ supplementation did not prevent cognitive decline in older diabetic patients with borderline vitamin B₁₂ status.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02457507.

Alzheimer's disease with cerebrovascular disease: current status in the Asia-Pacific region

BACKGROUND

There is growing awareness of the coexistence of Alzheimer's disease and cerebrovascular disease (AD+CVD), however, due to lack of well-defined criteria and treatment guidelines AD+CVD may be underdiagnosed in Asia.

METHODS

Sixteen dementia specialists from nine Asia Pacific countries completed a survey in September 2014 and met in November 2014 to review the epidemiology, diagnosis and treatment of AD+CVD in Asia. A consensus was reached by discussion, with evidence provided by published studies when available.

RESULTS

AD accounts for up to 60% and AD+CVD accounts for 10-20% of all dementia cases in Asia. The reasons for underdiagnosis of AD+CVD include lack of awareness as a result of a lack of diagnostic criteria, misdiagnosis as vascular dementia or AD, lack of diagnostic facilities, resource constraints and cost of investigations. There is variability in the tools used to diagnose AD+CVD in clinical practice. Diagnosis of AD+CVD should be performed in a stepwise manner of clinical evaluation followed by neuroimaging. Dementia patients should be assessed for cognition, behavioural and psychological symptoms, functional staging and instrumental activities of daily living. Neuroimaging should be performed using computed tomography or magnetic resonance imaging. The treatment goals are to stabilize or slow progression as well as to reduce behavioural and psychological symptoms, improve quality of life and reduce disease burden. First-line therapy is usually an acetylcholinesterase inhibitor such as donepezil.

CONCLUSION

AD+CVD is likely to be under-recognised in Asia. Further research is needed to establish the true prevalence of this treatable and potentially preventable disease.

Intensity and Types of Physical Exercise in Relation to Dementia Risk Reduction in Community-Living Older Adults

OBJECTIVE

To systematically examine the amount and type of physical exercise that might reduce the future risk of dementia in community-living older people.

DESIGN

Six-year observational study.

SETTING

All the Elderly Health Centers (EHCs) of the Department of Health in Hong Kong.

PARTICIPANTS

A total of 15,589 community-living Chinese aged 65 years and older with no history of stroke, clinical dementia, or Parkinson disease when they completed health assessment at the EHCs in the first 6 months of 2005.

MEASUREMENTS

Self-reported habitual physical exercise patterns, including the frequency, duration, and type of exercise, at baseline and Year 3 were analyzed. The study outcome was incident dementia in 6 years. Dementia was defined by presence of clinical dementia in accordance with the 10th revision of the International Statistical Classification of Diseases and Related Health Problems or Clinical Dementia Rating of 1 to 3.

RESULTS

Both the cognitively stable and incident groups reported exercising a median of 7 days per week and 45 minutes per day at baseline and Year 3. The former practiced aerobic and mind-body exercises more at baseline and Year 3, whereas the latter practiced stretching and toning exercises more. The odds ratio for dementia remained significant for aerobic (0.81; 95% confidence interval 0.68-0.95; P = .01) and mind-body exercises (0.76; 0.63-0.92; P = .004) after excluding participants who developed dementia within 3 years after baseline and adjusting for important potential confounders, such as age, gender, educational level, and physical and psychiatric comorbidities.

CONCLUSION

Although physical exercise is widely promoted as a nonpharmacological intervention for dementia prevention, not all types of exercise appear to be useful in reducing risk of dementia in older people. Our findings suggest that daily participation in aerobic and mind-body but not stretching and toning exercises might protect community-living older adults from developing dementia.

Associations between the neighbourhood environment characteristics and physical activity in older adults with specific types of chronic conditions: the ALECS cross-sectional study

Background

Neighbourhood characteristics may influence physical activity (PA), which has positive effects on the health of older adults. Older adults with chronic conditions are less active and possibly more affected by environmental factors than their peers. Understanding neighbourhood characteristics associated with PA specific to older adults with chronic conditions is currently lacking. This cross-sectional study aimed to assess the associations between the neighbourhood environment and various forms of PA in older adults with and without visual impairment, hearing impairment, musculoskeletal disease and/or genitourinary disease.

Methods

Neighbourhood environment and PA data were collected in Hong Kong older adults (N = 909) from 124 preselected neighbourhoods stratified for walkability and socioeconomic status. Generalized linear models and zero-inflated negative binomial models with robust standard errors were used to examine associations of perceived neighbourhood environment characteristics, and the moderating effects of having specific chronic conditions, with PA outcomes.

Results

Thirteen perceived neighbourhood characteristics were associated with older adults’ PA in the expected direction irrespective of their health condition. Nine neighbourhood characteristics had associations with PA that were dependent on hearing impairment, vision impairment, musculoskeletal disease or genitourinary disease. In general, they were stronger in participants with than without a specific chronic condition.

Conclusions

Maximizing the potential for PA in older adults who have lower levels of physical functionality due to chronic conditions may require neighbourhood characteristics specific to these groups.

Decreased Proportion of Dementia-Free Life Expectancy in Hong Kong SAR

BACKGROUND

Estimations of life expectancies (LE) in health and ill health are important for planning future health care support. This study aimed at quantifying whether an increased LE is accompanied by an increase in the duration of life with dementia (DemLE) in Hong Kong SAR.

METHODS

Two parameters from a logistic model were used to fit the overall trend of the weighted prevalence of dementia. Abridged age- and sex-specific life tables and Sullivan's method were used to calculate dementia-free LE (DemFLE) for 1998 and 2013.

RESULTS

In 2013, among elderly individuals in Hong Kong aged 65 years, men had lived with dementia for 1.8 years and women for 3.6 years. These values are similar to those for subjects aged ≥85 years, while the proportion of DemLE was much greater at advanced ages. Elderly female individuals tend to experience a greater number of years with dementia than males.

CONCLUSION

Our results indicate although LE has increased for all older age groups over time, the increase in DemFLE has not been greater than the gain in LE, suggesting an absolute expansion of the burden of dementia to the community between 1998 and 2013. The results suggest that more caregiving resources and manpower will be needed in the future as the population ages.

The China longitudinal ageing study: overview of the demographic, psychosocial and cognitive data of the Shanghai sample

BACKGROUND

China's ageing population will lead to increased neurodegenerative illness and age-related mental health problems.

AIMS

The Chinese Longitudinal Ageing Study has been developed to better understand the impact of ageing on cognition and mental health. An overview of the sample, major diagnoses and results of the first wave of data collection is presented.

METHOD

One thousand and sixty-eight elderly Chinese (42.2% male), mean age of 72.8 years (SD = 8.5) completed a comprehensive cognitive, psychosocial and mental health assessment.

RESULTS

Mean MMSE score was 24.73 (SD = 6.17). Primary generalised anxiety was detected in 0.4% of the sample. Sub-clinical depression and depressive disorder were diagnosed in 1.7% and 2.4% of the sample, respectively. Most (84.5%) reported subjective memory decline, however 66.5% had no cognitive impairment. Mild Cognitive Impairment (MCI) was detected in 25%, Alzheimer's disease (AD) in 4.7%, vascular dementia in 2.5%, and mixed dementia in 1.3%. Cognition was worse in those 85+ years, but affective disorder rates were not.

CONCLUSION

Higher rates of dementia were detected than previously reported in China. Normative data is presented for common cognitive and mental health assessment and screening tasks in a Chinese population. This suggests that the true incidence of dementia has been underestimated, and requires further investigation.

Neighbourhood environment, physical activity, quality of life and depressive symptoms in Hong Kong older adults: a protocol for an observational study

INTRODUCTION

The neighbourhood environment can assist the adoption and maintenance of an active lifestyle and affect the physical and mental well-being of older adults. The psychosocial and behavioural mechanisms through which the environment may affect physical and mental well-being are currently poorly understood.

AIM

This observational study aims to examine associations between the physical and social neighbourhood environments, physical activity, quality of life and depressive symptoms in Chinese Hong Kong older adults.

METHODS AND ANALYSES

An observational study of the associations of measures of the physical and social neighbourhood environment, and psychosocial factors, with physical activity, quality of life and depressive symptoms in 900 Hong Kong older adults aged 65+ years is being conducted in 2012-2016. The study involves two assessments taken 6 months apart. Neighbourhood walkability and access to destinations are objectively measured using Geographic Information Systems and environmental audits. Demographics, socioeconomic status, walking for different purposes, perceived neighbourhood and home environments, psychosocial factors, health status, social networks, depressive symptoms and quality of life are being assessed using validated interviewer-administered self-report measures and medical records. Physical functionality is being assessed using the Short Physical Performance Battery. Physical activity and sedentary behaviours are also being objectively measured in approximately 45% of participants using accelerometers over a week. Physical activity, sedentary behaviours, quality of life and depressive symptoms are being assessed twice (6 months apart) to examine seasonality effects on behaviours and their associations with quality of life and depressive symptoms.

ETHICS AND DISSEMINATION

The study received ethical approval from the University of Hong Kong Human Research Ethics Committee for Non-Clinical Faculties (EA270211) and the Department of Health (Hong Kong SAR). Data are stored in a password-protected secure database for 10 years, accessible only to the named researchers. Findings will be submitted for publication in peer-reviewed journals.

Prevalence of Cognitive Impairment Among Peritoneal Dialysis Patients, Impact on Peritonitis and Role of Assisted Dialysis

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BACKGROUND

Chronic renal failure and aging are suggested as risk factors for cognitive impairment (CI). We studied the prevalence of CI among peritoneal dialysis (PD) patients using Montreal Cognitive Assessment (MoCA), its impact on PD-related peritonitis in the first year, and the potential role of assisted PD. ♦

METHODS

One hundred fourteen patients were newly started on PD between February 2011 and July 2013. Montreal Cognitive Assessment was performed in the absence of acute illness. Data on patient characteristics including demographics, comorbidities, blood parameters, dialysis adequacy, presence of helpers, medications, and the number PD-related infections were collected. ♦

RESULTS

The age of studied patients was 59±15.0 years, and 47% were female. The prevalence of CI was 28.9%. Patients older than 65 years old (odds ratio [OR] 4.88, confidence interval [CI] 1.79 - 13.28 p = 0.002) and with an education of primary level or below (OR 4.08, CI 1.30 - 12.81, p = 0.016) were independent risk factors for CI in multivariate analysis. Patients with PD-related peritonitis were significantly older (p < 0.001) and more likely to have CI as defined by MoCA (p = 0.035). After adjustment for age, however, CI was not a significant independent risk factor for PD-related peritonitis among self-care PD patients (OR 2.20, CI 0.65 - 7.44, p = 0.20). When we compared patients with MoCA-defined CI receiving self-care and assisted PD, there were no statistically significant differences between the 2 groups in terms of age, MoCA scores, or comorbidities. There were also no statistically significant differences in 1-year outcome of PD-related peritonitis rates or exit-site infections. ♦

CONCLUSION

Cognitive impairment is common among local PD patients. Even with CI, peritonitis rate in self-care PD with adequate training is similar to CI patients on assisted PD.

Prevalence of Mental Illness among Homeless People in Hong Kong

Metholodogy

This study examined the prevalence and correlates of mental illness in homeless people in Hong Kong and explored the barriers preventing their access to health care. Ninety-seven Cantonese-speaking Chinese who were homeless during the study period were selected at random from the records of the three organisations serving the homeless population. The response rate was 69%. Seventeen subjects could not give valid consent due to their poor mental state, so their responses were excluded from the data analysis. A psychiatrist administered the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I) and the Mini -Mental State Examination. Consensus diagnoses for subjects who could not complete the SCID-I were established by three independent psychiatrists.

Findings

The point prevalence of mental illness was 56%. Seventy-one percent of the subjects had a lifetime history of mental illness, 30% had a mood disorder, 25% had an alcohol use disorder, 25% had a substance use disorder, 10% had a psychotic disorder, 10% had an anxiety disorder and 6% had dementia. Forty-one percent of the subjects with mental illness had undergone a previous psychiatric assessment. Only 13% of the subjects with mental illness were receiving psychiatric care at the time of interview. The prevalence of psychotic disorders, dementia and the rate of under treatment are hugely underestimated, as a significant proportion (18%) of the subjects initially selected were too ill to give consent to join the study.

Conclusion

The low treatment rate and the presence of this severely ill and unreached group of homeless people reflect the fact that the current mode of service delivery is failing to support the most severely ill homeless individuals.

Effect of Low-intensity Exercise on Physical and Cognitive Health in Older Adults: a Systematic Review

Background

It is well known that physical exercise is important to promote physical and cognitive health in older population. However, inconsistent research findings were shown regarding exercise intensity, particularly on whether low-intensity exercise (1.5 metabolic equivalent tasks (METs) to 3.0 METs) can improve physical and cognitive health of older adults. This systematic review aimed to fill this research gap. The objective of this study is to conduct a systematic review of the effectiveness of low-intensity exercise interventions on physical and cognitive health of older adults.

Methods

Published research was identified in various databases including CINAHL, MEDLINE, PEDro, PubMed, Science Direct, SPORTDiscus, and Web of Science. Research studies published from January 01, 1994 to February 01, 2015 were selected for examination. Studies were included if they were published in an academic peer-reviewed journal, published in English, conducted as randomized controlled trial (RCT) or quasi-experimental studies with appropriate comparison groups, targeted participants aged 65 or above, and prescribed with low-intensity exercise in at least one study arm. Two reviewers independently extracted the data (study, design, participants, intervention, and results) and assessed the quality of the selected studies. Fifteen studies met the inclusion criteria. Quality index ranged from 15 to 18 mean = 18.3 with a full score of 28, indicating a moderate quality. Most of the outcomes reported in these studied were lower limb muscle strength (n = 9), balancing (n = 7), flexibility (n = 4), and depressive symptoms (n = 3).

Results

Out of the 15 selected studies, 11 reported improvement in flexibility, balancing, lower limb muscle strength, or depressive symptoms by low-intensity exercises.

Conclusions

The current literature suggests the effectiveness of low-intensity exercise on improved physical and cognitive health for older adults. It may be a desired intensity level in promoting health among older adults with better compliance, lower risk of injuries, and long-term sustainability.

Intellectual and physical activities, but not social activities, are associated with better global cognition: a multi-site evaluation of the cognition and lifestyle activity study for seniors in Asia (CLASSA)

BACKGROUND

population ageing will lead to a leap in the dementia population in Asia. However, information about potentials for low-cost and low-risk interventions is limited.

OBJECTIVES

to study the associations between lifestyle activities and global cognition from the Cognitive and Lifestyle Activity Study for Seniors in Asia (CLASSA).

DESIGN

a cross-sectional study.

METHODOLOGY

we studied the association between global cognition and lifestyle activity participation in community living older adults (60 years or over) across nine sites in East Asia. A standardised lifestyle activity questionnaire exploring activities from four categories (intellectual, physical, social and recreational) was used to measure the pattern. Global cognition was categorised by locally validated versions of Mini-mental state examination (MMSE) or Montreal Cognitive Assessment (MoCA) (good cognition, GC-scored at the top 25% among participants with no significant cognitive deficit (SCD); normal cognition, NC-middle 50% among participants with no SCD; mild cognitive deficit, MCD-lowest 25% among participants with no SCD; SCD-below local cut-offs for dementia).

RESULTS

two thousand four hundred and four (1,009 men; 1,395 women) participants were recruited. The mean age was 71.0 (7.2) years. A higher variety of intellectual and physical activities were associated with GC; more social activities were associated with higher risks of having impaired cognition (multinomial logistic regression). The same association was found in participants with no SCD and had regular activities for over 10 years (n = 574).

CONCLUSION

intellectual activity and physical exercise were associated with better cognitive states in Asian older adults. Community-based intervention may take considerations into specific types of activities to optimise cognition.

Would older adults with mild cognitive impairment adhere to and benefit from a structured lifestyle activity intervention to enhance cognition?: a cluster randomized controlled trial

Background

Epidemiologic evidence suggests that cognitive and physical activities are associated with better cognition in late life. The present study was conducted to examine the possible benefits of four structured lifestyle activity interventions and compare their effectiveness in optimizing cognition for older adults with mild cognitive impairment (MCI).

Method and Findings

This was a 12-month cluster randomized controlled trial. 555 community-dwelling Chinese older adults with MCI (295 with multiple-domain deficits (mdMCI), 260 with single-domain deficit (sdMCI)) were recruited. Participants were randomized into physical exercise (P), cognitive activity (C), integrated cognitive and physical exercise (CP), and social activity (S, active control) groups. Interventions comprised of one-hour structured activities three times per week. Primary outcome was Clinical Dementia Rating sum of boxes (CDR-SOB) scores. Secondary outcomes included Chinese versions of Alzheimer’s Disease Assessment Scale - Cognitive subscale (ADAS-Cog), delayed recall, Mini-Mental State Examination, Category Verbal Fluency Test (CVFT) and Disability Assessment for Dementia – Instrumental Activities of Daily Living (DAD-IADL). Percentage adherence to programs and factors affecting adherence were also examined. At 12th month, 423 (76.2%) completed final assessment. There was no change in CDR-SOB and DAD-IADL scores across time and intervention groups. Multilevel normal model and linear link function showed improvement in ADAS-Cog, delayed recall and CVFT with time (p<0.05). Post-hoc subgroup analyses showed that the CP group, compared with other intervention groups, had more significant improvements of ADAS-Cog, delayed recall and CVFT performance with sdMCI participants (p<0.05). Overall adherence rate was 73.3%. Improvements in ADAS-Cog and delayed recall scores were associated with adherence after controlling for age, education, and intervention groups (univariate analyses).

Conclusions

Structured lifestyle activity interventions were not associated with changes in everyday functioning, albeit with some improvements in cognitive scores across time. Higher adherence was associated with greater improvement in cognitive scores. Factors to enhance adherence should be specially considered in the design of psychosocial interventions for older adults with cognitive decline.

Trial Registration

ClinicalTrials.gov ChiCTR-TRC-11001359

Incidence of Alzheimer's disease in India: a 10 years follow-up study

OBJECTIVE

To determine overall and age-specific incidence rates of Alzheimer's disease (AD) in a southern Indian province, Kerala.

MATERIALS AND METHODS

A 10-year (2001-2011) prospective epidemiologic study of community residing subjects aged ≥55 years at enrollment. The catchment area included four urban and semi-urban regions of Trivandrum city in Kerala, India, was selected to provide a range of demographic and socioeconomic representation. Cognitive and functional ability screening were done at baseline and 24-month follow-up assessments. Consensus diagnostic procedures were done using the Diagnostic and Statistical Manual of Mental Disorders, 4 th edition (DSM-IV), and the National Institute of Neurological and Communicative Disorders and Stroke - Alzheimer's Disease and Related Disorders Association (NINDS-ADRDA) criteria for the diagnosis of dementia and AD.

RESULTS

Among the 1066 eligible participants who were cognitively normal at baseline, 104 developed dementia (98 with AD) over a follow-up period of 8.1 years. The incidence rates per 1000 person-years for AD was 11.67 (95% CI: 10.9-12.4) for those aged ≥55 years and higher for those aged ≥65 years (15.54, 95% CI: 14.6-16.5). In those aged ≥65 years, the world age standardized incidence rate was 21.61 per 100,000, and standardized against the age distribution for the year 2000 U.S. Census, the age-adjusted incidence rate was 9.19 (95% CI: 9.03-9.35) per 1000 person-years. Incidence rate of AD increased significantly and proportionately with increasing age.

CONCLUSION

These are the first AD incidence rates to be reported from southern India. The incidence rates appear to be much higher than that reported from rural north India, comparable with that reported from China, and marginally lower than that reported from the western world.

Case management approaches to home support for people with dementia

BACKGROUND

Over 35 million people are estimated to be living with dementia in the world and the societal costs are very high. Case management is a widely used and strongly promoted complex intervention for organising and co-ordinating care at the level of the individual, with the aim of providing long-term care for people with dementia in the community as an alternative to early admission to a care home or hospital.

OBJECTIVES

To evaluate the effectiveness of case management approaches to home support for people with dementia, from the perspective of the different people involved (patients, carers, and staff) compared with other forms of treatment, including 'treatment as usual', standard community treatment and other non-case management interventions.

SEARCH METHODS

We searched the following databases up to 31 December 2013: ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group,The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, Web of Science (including Science Citation Index Expanded (SCI-EXPANDED) and Social Science Citation Index), Campbell Collaboration/SORO database and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group. We updated this search in March 2014 but results have not yet been incorporated.

SELECTION CRITERIA

We include randomised controlled trials (RCTs) of case management interventions for people with dementia living in the community and their carers. We screened interventions to ensure that they focused on planning and co-ordination of care.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as required by The Cochrane Collaboration. Two review authors independently extracted data and made 'Risk of bias' assessments using Cochrane criteria. For continuous outcomes, we used the mean difference (MD) or standardised mean difference (SMD) between groups along with its confidence interval (95% CI). We applied a fixed- or random-effects model as appropriate. For binary or dichotomous data, we generated the corresponding odds ratio (OR) with 95% CI. We assessed heterogeneity by the I² statistic.

MAIN RESULTS

We include 13 RCTs involving 9615 participants with dementia in the review. Case management interventions in studies varied. We found low to moderate overall risk of bias; 69% of studies were at high risk for performance bias.The case management group were significantly less likely to be institutionalised (admissions to residential or nursing homes) at six months (OR 0.82, 95% CI 0.69 to 0.98, n = 5741, 6 RCTs, I² = 0%, P = 0.02) and at 18 months (OR 0.25, 95% CI 0.10 to 0.61, n = 363, 4 RCTs, I² = 0%, P = 0.003). However, the effects at 10 - 12 months (OR 0.95, 95% CI 0.83 to 1.08, n = 5990, 9 RCTs, I² = 48%, P = 0.39) and 24 months (OR 1.03, 95% CI 0.52 to 2.03, n = 201, 2 RCTs, I² = 0%, P = 0.94) were uncertain. There was evidence from one trial of a reduction in the number of days per month in a residential home or hospital unit in the case management group at six months (MD -5.80, 95% CI -7.93 to -3.67, n = 88, 1 RCT, P < 0.0001) and at 12 months (MD -7.70, 95% CI -9.38 to -6.02, n = 88, 1 RCT, P < 0.0001). One trial reported the length of time until participants were institutionalised at 12 months and the effects were uncertain (hazard ratio (HR): 0.66, 95% CI 0.38 to 1.14, P = 0.14). There was no difference in the number of people admitted to hospital at six (4 RCTs, 439 participants), 12 (5 RCTs, 585 participants) and 18 months (5 RCTs, 613 participants). For mortality at 4 - 6, 12, 18 - 24 and 36 months, and for participants' or carers' quality of life at 4, 6, 12 and 18 months, there were no significant effects. There was some evidence of benefits in carer burden at six months (SMD -0.07, 95% CI -0.12 to -0.01, n = 4601, 4 RCTs, I² = 26%, P = 0.03) but the effects at 12 or 18 months were uncertain. Additionally, some evidence indicated case management was more effective at reducing behaviour disturbance at 18 months (SMD -0.35, 95% CI -0.63 to -0.07, n = 206, 2 RCTs I² = 0%, P = 0.01) but effects were uncertain at four (2 RCTs), six (4 RCTs) or 12 months (5 RCTs).The case management group showed a small significant improvement in carer depression at 18 months (SMD -0.08, 95% CI -0.16 to -0.01, n = 2888, 3 RCTs, I² = 0%, P = 0.03). Conversely, the case management group showed greater improvement in carer well-being in a single study at six months (MD -2.20 CI CI -4.14 to -0.26, n = 65, 1 RCT, P = 0.03) but the effects were uncertain at 12 or 18 months. There was some evidence that case management reduced the total cost of services at 12 months (SMD -0.07, 95% CI -0.12 to -0.02, n = 5276, 2 RCTs, P = 0.01) and incurred lower dollar expenditure for the total three years (MD= -705.00, 95% CI -1170.31 to -239.69, n = 5170, 1 RCT, P = 0.003). Data on a number of outcomes consistently indicated that the intervention group received significantly more community services.

AUTHORS' CONCLUSIONS

There is some evidence that case management is beneficial at improving some outcomes at certain time points, both in the person with dementia and in their carer. However, there was considerable heterogeneity between the interventions, outcomes measured and time points across the 13 included RCTs. There was some evidence from good-quality studies to suggest that admissions to care homes and overall healthcare costs are reduced in the medium term; however, the results at longer points of follow-up were uncertain. There was not enough evidence to clearly assess whether case management could delay institutionalisation in care homes. There were uncertain results in patient depression, functional abilities and cognition. Further work should be undertaken to investigate what components of case management are associated with improvement in outcomes. Increased consistency in measures of outcome would support future meta-analysis.

Validation of the Cambridge Prospective Memory Test (Hong Kong Chinese version) for people with stroke

This study aimed to develop and evaluate a Hong Kong Chinese version of the Cambridge Prospective Memory Test (CAMPROMPT-HKCV). Thirty-three subjects at least one year post-stroke participated in the study. They were simultaneously rated on version A of the CAMPROMPT-HKCV by two testers to establish its internal consistency and inter-rater reliability. Raters used the parallel versions of the test (A and B), in rating 10 patients within 2 weeks to establish the parallel form reliability. Another 10 were also assessed on the same day using both version A of the CAMPROMPT-HKCV and the Rivermead Behavioural Memory Test-Chinese version (RBMT-CV) to establish concurrent validity. A new group of 40 stroke patients and 44 healthy controls was recruited to establish its sensitivity and specificity. Results indicated that test-retest reliability on time-based, event-based and total scores, and inter-rater reliability for versions A and B of the test were high. Cronbach's alpha of the event-based score was higher than that of the time-based score. The reliability and concurrent validity of the parallel forms were established. There was a significant difference in performance on CAMPROMPT-HKCV (version A) between the stroke group and the healthy control group. ROC analysis showed that the ability of the cut-off CAMPROMPT-HKCV (total score) to differentiate PM problems was 20.5 (out of 36) with sensitivity at 95.5% and specificity at 55.9%. Further study in developing stratified norms across different age groups in Chinese-speaking stroke patients is recommended.

Bias in discriminating very mild dementia for older adults with different levels of education in Hong Kong

BACKGROUND

Education has a profound effect on older adults' cognitive performance. In Hong Kong, some dementia screening tasks were originally designed for developed population with, on average, higher education.

METHODS

We compared the screening power of these tasks for Chinese older adults with different levels of education. Community-dwelling older adults who were healthy (N = 383) and with very mild dementia (N = 405) performed the following tasks: Mini-Mental State Examination, Alzheimer's Disease Assessment Scale-Cognitive subscales, Verbal Fluency, Abstract Thinking, and Visual/Digit Span. Logistic regression was used to examine the power of these tasks to predict Clinical Dementia Rating (CDR 0.5 vs. 0).

RESULTS

Logistic regression analysis showed that while the screening power of the total scores in all tasks was similar for high and low education groups, there were education biases in some items of these tasks.

CONCLUSION

The differential screening power in high and low education groups was not identical across items in some tasks. Thus, in cognitive assessments, we should exercise great caution when using these potentially biased items for older adults with limited education.

Efficacy of classic Chinese medicine formula Ditan Decoction () for Alzheimer's disease

OBJECTIVE

Determine the efficacy and safety of classic Chinese medicine formula Ditan Decoction (, DTD) for the treatment of Alzheimer's disease (AD) by reviewing the methods and results reported in laboratory and clinical studies in order to suggest strategies for developing more effective drugs for AD.

METHODS

Embase (OVID) and China Journal Net (CJN) were searched for articles published between 1947 to November 2011 and 1915 to November 2011 respectively. Articles that fulfilled the inclusion criteria and did not meet the exclusion criteria were collected and compared in terms of research method, interventions and outcomes.

RESULTS

No articles were found in Embase (OVID); 8 were found in CJN (4 laboratory studies; 4 clinical studies). The laboratory studies showed that memory impairment of AD mice models were significantly improved by DTD. The clinical studies showed that Chinese medicine which include DTD, can also relieve the memory impairment of AD patients, however, the data about the exactly effectiveness of DTD was inconclusive.

CONCLUSIONS

All the clinical trials have not been fully designed yet. The evidences for recommending DTD in clinical practice were methodologically flawed. Rigid randomization in controlled clinical trials of DTD with adequate blinding and rating methods are highly recommended.

Dementia studies in Chinese populations

Variations in the prevalence of dementia in different ethnic groups have been reported worldwide, and a number of reviews have provided a picture of epidemiological studies in dementia research. However, little is known about epidemiological studies in Chinese populations. In this review, we searched PubMed and the Web of Science for original research articles published in English up to July 2013 on the prevalence, incidence, risk factors, and prognosis of dementia in Chinese populations worldwide. Except for the prevalence, we included only population-based follow-up studies. We identified 25 studies in elderly Chinese residents in Mainland China, Hong Kong, Taiwan, and Singapore, and found a higher prevalence of dementia in Mainland China than in the other locations, which may be due to that the studies from Mainland China are more recent than those from other locations. A notable increase in incidence was observed when dementia cases were diagnosed using 10/66 diagnostic criteria compared to other criteria. Studies on risk factors for dementia were limited and mostly from Mainland China. Age, gender, education, smoking, and alcohol consumption were related to the risk of dementia in Chinese populations. Only two prognostic studies were identified, and age, gender, and residential area were related to the prognosis of dementia. In conclusion, the prevalence, incidence, and risk factors for dementia found in Chinese populations were comparable to other ethnic groups, but no conclusive results on prognosis were found. The differences in prevalence and incidence were influenced by the diagnostic criteria and the time of study. Longitudinal population-based studies on the incidence, risk factors, and prognosis of dementia in Chinese populations are required.

Translation and validation of Chinese version of the problems in everyday living (PEDL) test in patients with mild cognitive impairment

BACKGROUND

Cognitive impairment places older adults at increased risk of functional decline, injuries, and hospitalization. Assessments to determine whether older persons are still capable of meeting the cognitive challenges of everyday living are crucial to ensure their safe and independent living in the community. The present study aims to translate and validate the Chinese version of the Problems in Everyday Living (PEDL) test for use in Chinese population with mild cognitive impairment (MCI).

METHODS

The cultural relevancy and content validity of the Chinese version of PEDL (C-PEDL) was evaluated by a seven-member expert panel. Forty patients with MCI and 40 cognitively healthy participants were recruited to examine the psychometric properties of C-PEDL.

RESULTS

Significant differences in the C-PEDL scores were found between the patients with MCI and the cognitively healthy controls in both educated (F = 9.96, p = 0.003) and illiterate (F = 10.43, p = 0.004) populations. The C-PEDL had excellent test-retest and inter-rater reliabilities, with intraclass correlation coefficient at 0.95 and 0.99 respectively. The internal consistency of C-PEDL was acceptable with Chronbach's α at 0.69. The C-PEDL had moderate correlation with the Mini-Mental State Examination (r = 0.45, p = 0.004) and the Category Verbal Fluency Test (r = 0.40, p = 0.012), and a moderate negative Spearman's correlation with the Global Deteriorating Scale (r = -0.42, p = 0.007).

CONCLUSIONS

The C-PEDL is a valid and reliable test for assessing the everyday problem-solving ability in Chinese older population with MCI.

Association between body mass index and cause-specific mortality as well as hospitalization in frail Chinese older adults

AIM

A U-shaped relationship between body mass index (BMI) and all-cause mortality has been reported, but there are few studies examining the association between BMI and cause-specific mortality and hospitalization. We carried out a longitudinal study to examine these associations in Chinese older adults with multiple comorbidities, which could provide a reference for the recommended BMI in this population.

METHODS

From 2004 to 2013, a retrospective cohort of Chinese older adults was selected from a geriatric day hospital in Hong Kong. They were divided into groups according to their BMI: BMI <16; BMI 16-18; BMI 18.1-20; BMI 20.1-22; BMI 22.1-24; BMI 24.1-26; BMI 26.1-28; BMI 28.1-30 and BMI >30. Other assessments included medical, functional, cognitive, social and nutritional assessment.

RESULTS

A total of 1747 older adults (mean age 80.8 ± 7.1 years, 44.1% male, 46.1% living in nursing homes, Charlson Comorbidity Index 2.0 ± 1.6) with a median follow up of 3.5 years were included. Older adults with BMI 24-28 had the lowest all-cause, infection-related and cardiovascular mortality (P < 0.001). Multivariate analysis showed that there was an inverted J-shaped association between BMI and hazard ratio for all-cause and infection-related mortality in both nursing home and community-dwelling older adults. The rate of all-cause hospitalization was lower in older adults with BMI 22-28 (P = 0.002). Multivariate analysis showed that there was an inverted J-shaped association between the odds ratio of recurrent hospitalization and BMI.

CONCLUSION

Chinese older adults with BMI 24-28 had lower all-cause mortality, infection-related mortality, cardiovascular-related mortality and all-cause hospitalization. This study provides a reference for the recommended BMI in this population.

Effects of education on very mild dementia among Chinese people in Hong Kong: potential mediators in the Cantonese Mini-Mental State Examination tasks

BACKGROUND

In Hong Kong, older Chinese adults generally have a low level of education. This study examined the effect of education on very mild Alzheimer's disease (AD), as quantified by Clinical Dementia Rating (CDR) scale (CDR 0.5 versus 0), in a Chinese community. The Cantonese version of the Mini-Mental State Examination (C-MMSE) was used to estimate cognitive abilities that were related to the level of education, and that in turn serve as protective factors for AD.

METHODS

A total of 788 community-dwelling older adults (383 CDR 0 and 405 CDR 0.5) were recruited in this cross-sectional study, which was derived from a population-based prevalence project. The participants' number of years of education and C-MMSE scores were used to predict their CDR scores using logistic regression and the mediation effects of C-MMSE scores were analyzed.

RESULTS

Consistent with previous studies, the chance of being rated as having very mild AD increased with age, but decreased with years of education, among the older adult community of Hong Kong. The effect of education on very mild dementia was weakened substantially when C-MMSE scores were included as mediating variables.

CONCLUSIONS

The findings indicate that the protective effects of education on dementia were mediated by an enhancement of older adults' performance on some C-MMSE items, including attention and orientation to time and place.

Determinants of job satisfaction in foreign domestic helpers caring for people with dementia in Hong Kong

The job satisfaction of live-in foreign domestic helpers (FDHs) may influence their caring motivation and the quality of care they provide, which may in turn affect the health status of care recipients. This study identifies the factors affecting job satisfaction of FDHs caring for people with dementia in Hong Kong, focusing especially on the role of FDHs' adaptation status, job self-efficacy and care recipients' situation. A total of 152 FDHs taking care of people with dementia were recruited from 6 day care centres for elderly people in Hong Kong when they attended with their care recipients. Data were collected from February to August 2011 and the response rate was 95%. Participants completed questionnaires which included measures of care recipients' dementia severity and disruptive behaviours, FDHs' demographic factors, personal adaptation status, caregiving self-efficacy and job satisfaction. Hierarchical regression analysis was conducted to analyse the data. The results showed that longer stay in Hong Kong, better fluency in Cantonese (local dialect), greater satisfaction in living conditions, higher caregiving self-efficacy and less disruptive behaviour of care recipients were independently associated with stronger job satisfaction in FDHs looking after people with dementia. On the basis of these findings, we would suggest that employers should consider helpers who have been in Hong Kong for a longer period of time and speak fluent Cantonese, and have previous experience of taking care of people with dementia. In addition, FDHs caring for people with dementia may benefit from carer training which improves their self-efficacy in dementia care.

Prevalence studies of dementia in mainland china, Hong Kong and taiwan: a systematic review and meta-analysis

BACKGROUND

Many studies have considered the prevalence of dementia in mainland China, Hong Kong and Taiwan. However, area level estimates have not been produced. This study examines area differences across mainland China, Hong Kong and Taiwan adjusting for the effect of methodological factors with the aim of producing estimates of the numbers of people with dementia in these areas.

METHOD AND FINDINGS

A search of Chinese and English databases identified 76 dementia prevalence studies based on samples drawn from mainland China, Hong Kong and Taiwan between 1980 and 2012. A pattern of significantly decreasing prevalence was observed from northern, central, southern areas of mainland China, Hong Kong and Taiwan. Area variations in dementia prevalence were not explained by differences in methodological factors (diagnostic criteria, age range, study sample size and sampling method), socioeconomic level or life expectancy between areas. The results of meta-analysis were applied to current population data to provide best estimate. Based on the DSM-IV diagnostic criteria, the total number of people aged 60 and over with dementia in mainland China, Hong Kong and Taiwan is 8.4 million (4.6%, 95% CI: 3.4, 5.8) and in northern, central and southern areas are 3.8 (5.1%, 95% CI: 4.1, 6.1), 3.2 (4.4%, 95% CI: 3.2, 5.6) and 1.2 (3.9%, 95% CI: 2.3, 5.4) million respectively. These estimates were mainly based on the studies existing in highly developed areas and potentially affected by incomplete and insufficient data.

CONCLUSIONS

The findings of this review provide a robust estimate of area differences in dementia prevalence. Application of the estimated prevalence to population data reveals the number of people with dementia is expected to double every 20 years, areas in mainland China will be facing the greatest dementia challenge.

Frontal lobe atrophy in depression after stroke

Background. Frontal lobe atrophy (FLA) is associated with late life depression. However, the role that FLA plays in the development of depression after stroke (DAS) remains unknown. This study thus examined the association between FLA and DAS. Methods. A convenience sample of 705 Chinese patients with acute ischemic stroke admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong participated in the study. A psychiatrist administered the Structural Clinical Interview for DSM-IV to all patients and made a diagnosis of DAS three months after the index stroke. Results. Eighty-five (12.1%) patients were diagnosed with DAS. In univariate analysis, the DAS patients were more likely to have severe FLA (14.1% versus 5.6%). Severe FLA remained an independent predictor of DAS in multivariate analysis, with an odds ratio of 2.6 (95% confidence intervals = 1.2–5.9). Conclusions. The results suggest that FLA may play a role in the pathogenesis of DAS, which supports the hypothesis that cumulative vascular burden may be important in predicting DAS. Further investigations are needed to clarify the impact of FLA on the clinical presentation, treatment response, and outcome of DAS in stroke survivors.

Effectiveness of cognitive training for Chinese elderly in Hong Kong

In Hong Kong, the evidence for cognitive-training programs in fighting against memory complaints is lacking. This study aimed to evaluate the effectiveness of the Active Mind cognitive-training program in improving the cognitive function and quality of life (QoL) for local community-dwelling Chinese older adults. A total of 200 subjects were recruited from 20 different district elderly community centers (DECCs). Centers were randomly assigned into either the intervention group or control group. The intervention group underwent eight 1-hour sessions of cognitive training, while the control group were included in the usual group activities provided by the DECCs. Standardized neuropsychological tests (the Chinese version of Mattis Dementia Rating Scale [CDRS] and the Cantonese version of the Mini-Mental State Examination) and the QoL questionnaire SF12 were used to assess participants’ cognitive function and QoL before and after the trial. A total of 176 subjects completed the study. The intervention group showed greater improvement in the cognitive function measured by total CDRS score (treatment: 12.24 ± 11.57 vs control: 4.37 ± 7.99; P < 0.001) and QoL measured by total SF12 score (treatment: 7.82 ± 13.19 vs control: 3.18 ± 11.61; P = 0.014). Subjects with lower education level were associated with better cognitive response to the cognitive-training program. The current findings indicated that the Active Mind cognitive-training program was effective in improving the cognitive function and QoL for community-dwelling Chinese older adults in Hong Kong.