Educational bias in the assessment of severe dementia: Brazilian cutoffs for severe Mini-Mental State Examination

Pharmacogenetics of angiotensin modulators according to APOE-ϵ4 alleles and the ACE insertion/deletion polymorphism in Alzheimer's disease

OBJECTIVE

In Alzheimer's disease (AD), angiotensin II receptor blockers (ARBs) could reduce cerebrovascular dysfunction, while angiotensin-converting enzyme inhibitors (ACEis) might increase brain amyloid-β by suppressing effects of the angiotensin-converting enzyme 1, an amyloid-β-degrading enzyme. However, ACEis could benefit patients with AD by reducing the amyloidogenic processing of the amyloid precursor protein, by central cholinergic and anti-inflammatory mechanisms, and by peripheral modulation of glucose homeostasis. We aimed to investigate whether the ACE insertion/deletion polymorphism is associated with clinical changes in patients with AD, while considering apolipoprotein E (APOE)-ϵ4 carrier status and blood pressure response to angiotensin modulators.

METHODS

Consecutive outpatients with late-onset AD were screened with cognitive tests and anthropometric measurements, while their caregivers were queried for functional and caregiver burden scores. Prospective pharmacogenetic associations were estimated for 1 year, taking APOE-ϵ4 carrier status and genotypes of the ACE insertion/deletion polymorphism into account, along with treatment with ACEis or ARBs.

RESULTS

For 193 patients (67.4% women, 53.4% APOE-ϵ4 carriers), the ACE insertion/deletion polymorphism was in Hardy-Weinberg equilibrium (p = 0.281), while arterial hypertension was prevalent in 80.3% (n = 124 used an ACEi, n = 21 used an ARB). ARBs benefitted mostly APOE-ϵ4 carriers concerning caregiver burden variations, cognitive and functional decline. ACEis benefitted APOE-ϵ4 non-carriers concerning cognitive and functional decline due to improved blood pressure control in addition to possible central mechanisms. The ACE insertion/deletion polymorphism led to variable response to angiotensin modulators concerning neurological outcomes and blood pressure variations.

CONCLUSION

Angiotensin modulators may be disease-modifiers in AD, while genetic stratification of samples is recommended in clinical studies.

Differential associations of clinical features with cerebrospinal fluid biomarkers in dementia with Lewy bodies and Alzheimer's disease

AIM

To explore associations of cerebrospinal fluid biomarkers of neurodegeneration and amyloidosis with caregiver burden, cognition and functionality in dementia with Lewy bodies (DLB) paired with late-onset Alzheimer's disease (AD) and healthy older people.

METHODS

Consecutive outpatients with DLB were matched with outpatients with AD according to sex, cognitive scores and dementia stage, and with cognitively healthy controls according to age and sex to investigate associations of cerebrospinal fluid amyloid-β (Aβ₄₂,Aβ₄₀,Aβ₃₈), tau, phospho-tau Thr₁₈₁, ubiquitin, α-synuclein and neurofilament light with caregiver burden, functionality, reverse digit span, a clock drawing test, Mini-Mental State Examination (MMSE) and Severe MMSE, adjusted for sex, age, education, dementia duration and APOE-ε4 alleles.

RESULTS

Overall, 27 patients with DLB (78.98 ± 9.0 years-old; eleven APOE-ε4 +) were paired with 27 patients with AD (81.50 ± 5.8 years-old; twelve APOE-ε4 +) and 27 controls (78.98 ± 8.7 years-old; four APOE-ε4 +); two-thirds were women. In AD, Aβ₄₂/Aβ₃₈ and Aβ₄₂ were lower, while tau/Aβ₄₂ and phospho-tau Thr₁₈₁/Aβ₄₂ were higher; α-synuclein/Aβ₄₂ was lower in DLB and higher in AD. The following corrected associations remained significant: in DLB, instrumental functionality was inversely associated with tau/phospho-tau Thr₁₈₁ and tau/Aβ₄₂, and reverse digit span associated with α-synuclein; in AD, instrumental functionality was inversely associated with neurofilament light, clock drawing test scores inversely associated with phospho-tau Thr₁₈₁/Aβ₄₂ and α-synuclein/Aβ₄₂, and Severe MMSE inversely associated with tau/Aβ₄₂ and tau/phospho-tau Thr₁₈₁.

CONCLUSIONS

Cerebrospinal fluid phospho-tau Thr₁₈₁ in DLB was similar to AD, but not Aβ₄₂. In associations with test scores, biomarker ratios were superior to isolated biomarkers, while worse functionality was associated with axonal degeneration only in AD.

COGNITO (Computerized assessment of adult information processing): Normative scores for a rural Indian population from the SANSCOG study

INTRODUCTION

Neuropsychological assessments are inexpensive and efficient methods to understand the cognitive abilities of individuals in research studies and clinical settings. Normative scores for such measures are crucial in serving as a reference standard for identifying cognitively healthy and impaired individuals belonging to similar sociodemographic characteristics.

METHODS

Study subjects in rural India recruited into the Srinivaspura Aging, Neuro Senescence and Cognition (SANSCOG) study were administered the COGNITO battery of tests, which traverse cognitive domains of attention, memory, language, and visuospatial abilities. Percentile norms based on age and education stratification were derived for the above cohort.

RESULTS

Percentile norms are commensurate with literacy levels in this population. The percentile scores for the cognitive tests show a decline for the individuals aged 75 years and above indicating lower cognitive functioning in this age group.

DISCUSSION

This is the first-ever study reporting norms for diverse cognitive domains for illiterate, literate, low-literate individuals enrolled in a large-scale community-based cohort study in rural India.

APOE ε4 Carrier Status as Mediator of Effects of Psychotropic Drugs on Clinical Changes in Patients With Alzheimer's Disease

OBJECTIVE

Neuropsychiatric syndromes have been associated with memory dysfunction and risk of and earlier onset of dementia, but how psychotropic drugs affect clinical changes in Alzheimer's disease is not entirely clear. This study aimed to assess the prospective effects of psychotropic drugs on cognitive and functional changes in Alzheimer's disease according to APOE ε4 carrier status.

METHODS

The study included consecutive outpatients with late-onset Alzheimer's disease (N=193) and examined score variations at 1 year on the following tests: Clinical Dementia Rating sum of boxes, Mini-Mental State Examination, Severe Mini-Mental State Examination (SMMSE), Brazilian version of the Zarit Caregiver Burden Interview, Index of Independence in Activities of Daily Living, and Lawton's Instrumental Activities of Daily Living Scale. Analyses of score variations accounted for the use of psychotropic drugs or the number of different medications in use, as well as APOE ε4 carrier status, with significance at p<0.05.

RESULTS

For APOE ε4 noncarriers (N=90), cholinesterase inhibitors were beneficial regarding caregiver burden (p=0.030) and basic functionality (p=0.046), memantine was harmful regarding SMMSE score changes (p=0.032), second-generation antipsychotics had nonsignificant harmful effects on SMMSE score changes (p=0.070), and antiepileptic therapy (p=0.001) and the number of different medications in use (p=0.006) were harmful in terms of basic functionality. APOE ε4 carriers (N=103) did not experience any effects of isolated psychotropic drugs on clinical changes, including antidepressants.

CONCLUSIONS

Results support the harmful prospective effects of second-generation antipsychotics and antiepileptic drugs on cognitive and functional changes in Alzheimer's disease, particularly for APOE ε4 noncarriers, whereas antidepressants may be safer options for behavioral enhancement.

Pharmacogenetic Analyses of Therapeutic Effects of Lipophilic Statins on Cognitive and Functional Changes in Alzheimer’s Disease

Background: Pharmacogenetic effects of statins on clinical changes in Alzheimer’s disease (AD) could be mediated by epistatic interactions among relevant genetic variants involved in cholesterol metabolism. Objective: To investigate associations of HMGCR (rs3846662), NR1H2 (rs2695121), or CETP (rs5882&rs708272) with cognitive and functional changes in AD, with stratification according to APOE ɛ4 carrier status and lipid-lowering treatment with lipophilic statins. Methods: Consecutive outpatients with late-onset AD were screened with cognitive tests, while caregivers scored functionality and global ratings, with prospective neurotranslational associations documented for one year. Results: Considering n = 190:142 had hypercholesterolemia, 139 used lipophilic statins; minor allele frequencies were 0.379 (rs2695121-T:46.3% heterozygotes), 0.368 (rs5882-G:49.5% heterozygotes), and 0.371 (rs708272-A:53.2% heterozygotes), all in Hardy-Weinberg equilibrium. For APOE ɛ4 carriers: rs5882-GG protected from cognitive decline; rs5882-AA caused faster cognitive decline; carriers of rs2695121-CC or rs5882-AA were more susceptible to harmful cognitive effects of lipophilic statins; carriers of rs5882-GG or rs708272-AG had functional benefits when using lipophilic statins. APOE ɛ4 non-carriers resisted any cognitive or functional effects of lipophilic statins, while invariability of rs3846662 (all AA) prevented the assessment of HMGCR effects. When assessing CETP haplotypes only: rs5882-GG protected from cognitive and functional decline, regardless of lipophilic statin therapy; lipophilic statins usually caused cognitive and functional harm to carriers of rs5882-A and/or rs708272-A; lipophilic statins benefitted cognition and functionality of carriers of rs5882-G and/or rs708272-G. Conclusion: Reportedly protective variants of CETP and NR1H2 also slowed cognitive and functional decline particularly for APOE ɛ4 carriers, and regardless of cholesterol variations, while therapy with lipophilic statins might affect carriers of specific genetic variants.

Accuracy of two prognostic indexes to predict mortality in older adults with advanced dementia

Dementia is a cause of disability among older adults. Accessing advanced dementia prognosis is a challenge.

Plasma S100β and neuron-specific enolase, but not neuroglobin, are associated with early cognitive dysfunction after total arch replacement surgery: A pilot study

To investigate whether plasma concentrations of S100β protein, neuron-specific enolase (NSE), and neuroglobin (NGB) correlate with early postoperative cognitive dysfunction (POCD) in patients undergoing total arch replacement.This prospective study analyzed 40 patients who underwent total arch replacement combined with stented elephant trunk implantation at our hospital between March 2017 and January 2019. Cognitive function was assessed using the Mini-mental State Examination (MMSE) preoperatively, on the day after extubation and on day 7 after surgery. Plasma levels of S100β, NSE, and NGB POCD were assayed preoperatively and at 1, 6, and 24 hours after cardiopulmonary bypass. POCD was defined as a decrease of at least 1 unit in the MMSE score from before surgery until day 7, and patients were stratified into those who experienced POCD or not. The 2 groups were compared in clinicodemographic characteristics and plasma levels of the 3 proteins.Plasma levels of all 3 biomarkers increased significantly during and after cardiopulmonary bypass. Levels of S100β and NSE, but not NGB, were significantly higher in the 15 patients who showed POCD than in the remainder who did not. For prediction of early POCD, S100β showed an area under the receiver operating characteristic curve (AUC) of 0.71 (95% confidence interval [CI] 0.55-0.87), sensitivity of 48%, and specificity of 87%. The corresponding values for NSE were 0.77 (95%CI 0.60-0.94), 92%, and 67%. Together, S100β and NSE showed an AUC of 0.81 (95%CI 0.66-0.96), sensitivity of 73%, and specificity of 80%. NGB did not significantly predict early POCD (AUC 0.62, 95%CI 0.43-0.80).Plasma S100β protein and NSE, but not NGB, may help predict early POCD after total arch replacement.

Swallowing in behavioral variant frontotemporal dementia

BACKGROUND

Swallowing and feeding problems may occur with the progression of behavioral variant frontotemporal dementia (bvFTD) and can impair the anticipatory and oral preparatory phases of swallowing.

OBJECTIVE

To characterize swallowing problems and the feeding situation of patients with bvFTD and to correlate the swallowing problems with functionality, executive functions, cognitive and behavioral features.

METHODS

Consecutive outpatients with bvFTD in mild, moderate and severe dementia stages were recruited along with their caregivers. Patients and caregivers were screened with the following scales: "Mini-Mental State Examination", "Severe Mini-Mental State Examination", "FTLD-modified Clinical Dementia Rating", "Neuropsychiatric Inventory", "Frontal Assessment Battery", "Index of Independence in Activities of Daily Living", "Swallowing Rating Scale" and "Assessment of Feeding and Swallowing Difficulties in Dementia".

RESULTS

Overall, thirty patients with bvFTD were included along with their caregivers. Patients with bvFTD showed feeding and swallowing difficulties such as: messy to eat, passivity, coughing and choking, difficulty with some food consistencies and with specific food. Swallowing problems in bvFTD correlated with impaired functionality (p<0.05) and cognition (p<0.05), executive dysfunction (p<0.01) and behavioral features (p<0.01). Caregivers had great difficulty in managing the feeding situation during mealtime, with different characteristics in each dementia stage.

CONCLUSION

Patients with bvFTD had inappropriate speed eating, passivity, coughing and choking starting in the mild dementia stage, and these problems worsen in the severe stage. Such difficulties affected caregiver performance during mealtime. The correlations indicated that swallowing difficulties tend to follow cognitive and behavioral decline in patients with bvFTD.

Cognitive Function Is a Prognostic Factor for Mortality of Nursing Home Residents during a 3-Year Observational Period

Introduction

Assessing cognitive function could help to provide appropriate care for nursing home residents. The aim of the study was to identify the factors affecting cognitive function in nursing home residents in Poland and assess how it influenced the mortality rate during a 3-year observational period.

Methods

This study included 202 elderly individuals from a nursing home in 2015. The investigation included examination of cognitive function using the MMSE and bioelectrical impedance analysis. Collected data included sex, age, blood pressure (BP), heart rate, number of comorbidities, years spent in the nursing home, educational level, and cigarette-smoking.

Results

The mean MMSE score was 21.36 ± 6.35, which was negatively correlated with age and diastolic BP (p = 0.001 and p = 0.024, respectively) and positively correlated with body mass, BMI, fat-free mass, fat, muscle mass, and education level (p = 0.004, p = 0.004, p = 002, p = 0.049, p = 0.005, and p ˂ 0.001, respectively). Patients who died during the observational period had lower MMSE scores than those who survived (23.34 ± 5.68 vs. 20.16 ± 6.45; p < 0.001). Smokers had better MMSE results than nonsmokers (23.34 ± 5.98 vs. 20.08 ± 4.94; p < 0.001).

Discussion

Polish nursing home residents had mild cognitive impairment depending on their age, sex, educational level, and nutritional status. Lower MMSE score was a prognostic factor for mortality in the 3-year observational period.

Cognitive Assessment Tools for Screening Older Adults With Low Levels of Education: A Critical Review

Introduction: Cognitive assessment of older adults who are either illiterate or with low levels of education is particularly challenging because several battery tasks require a certain educational background. Early detection of mild cognitive impairment (MCI) in the elderly using validated screening tools is of great importance since this population group could benefit from new drugs that are being investigated for the treatment of dementias. Cutoff scores for psychometric properties of cognitive tests are not well established among adults with low levels of education. The present study aimed to critically review the literature on cognitive assessment tools for screening cognitive syndromes including MCI and Alzheimer's disease (AD) in older adults with low levels of education. Methods: We conducted a systematic search of MEDLINE, LILACS, Cochrane, and SCOPUS electronic databases of cross-sectional and prospective studies with adults over 55 years of age. Results: We found a significant number of assessment tools available (n = 44), but only a few of them showed diagnostic accuracy for the diagnosis of MCI and AD in older adults with low levels of education: the Mini-Mental State Exam; the Montreal Cognitive Assessment; the Persian Test of Elderly for Assessment of Cognition and Executive Function; the Six-Item Screener; and the Memory Alteration Test. Few studies evaluated individuals with low levels of education, with a wide range of cutoff scores and cognitive test batteries. Conclusion: We found that a small number of studies evaluated adults with 4 years of formal education or less. Our findings further support the importance of developing specific tools for the assessment of older adults with low levels of education.

Dealing with severe dementia in clinical practice: A validity and reliability study of Severe Mini-Mental State Examination in Greek population

Objective

Considering the floor effect problems of many cognitive instruments administered in patients with dementia, we aimed to evaluate the validity and reliability of the Severe Mini‐Mental State Examination (SMMSE) for monitoring patients with moderate to severe dementia in the Greek population.

Methods

We included 210 patients with dementia, mostly diagnosed with Alzheimer's disease, and administered the SMMSE, the Mini‐Mental State Examination (MMSE), the Global Deterioration Scale, and the Katz Activities of Daily Living Scale (ADL). Demographic effects on SMMSE, validity, and reliability properties were initially tested for the total sample; SMMSE diagnostic accuracy was examined between subgroups of patients according to their MMSE performance; longitudinal changes over a 6‐month period were assessed for a subgroup of 100 patients.

Results

None of the demographic variables correlated with SMMSE score. Reliability analysis revealed high indices regarding internal consistency, inter‐rater, and test‐retest reliability. Validity analysis showed high correlation coefficients between SMMSE, MMSE, Global Deterioration Scale, and Katz Activities of Daily Living Scale (concurrent validity) and excellent discriminant validity of SMMSE to correctly categorize patients based on their MMSE score. In the longitudinal analysis, we found significant differences (1) only on SMMSE for patients with an MMSE = 0 to 6 at baseline and (2) both on SMMSE and MMSE for patients with an MMSE = 7 to 16 at baseline. No differences were detected for patients with an MMSE = 17 to 22 at baseline.

Conclusions

We suggest the SMMSE as quick, reliable, valid, and insensitive to demographic effects psychometric instrument to monitor cognitive changes in patients with profoundly severe dementia.

Dementia and legal determination of capacity

OBJECTIVE

To assess the legal capacity and guardianship proceedings in patients diagnosed with dementia.

METHODS

Ninety-seven patients diagnosed with dementia and seen at a tertiary hospital were evaluated.

RESULTS

Of these 97 patients, 60 (62%) were female. The mean age of the patients was 77.9 years; average schooling was 5.5 years. The main diagnosis was Alzheimer's disease (73%): 16 patients were at a mild stage, eight at a moderate stage and 73 at an advanced stage of dementia. Only 28 patients had been legally declared incapable.

CONCLUSION

The large numbers of patients at an advanced stage of dementia, and the relatively few patients legally declared incapable show that legal issues in dementia are problematic.

A cross-sectional study to evaluate metabolic and demographic factors affecting cognitive function among low educated internal medicine outpatients

OBJECTIVE

To evaluate factors affecting cognitive function in internal medicine outpatients.

METHODS

A total of 130 consecutive outpatients aged 50-80 years old were included in this cross-sectional study conducted at Okmeydani Training and Research Hospital, Istanbul, Turkey between March and May 2013. Cognitive function was evaluated via Standardized Mini-Mental State Examination (SMMSE) scores. Logistic regression analysis was performed to determine factors predicting poor cognitive function.

RESULTS

Mild-to-moderate cognitive impairment was noted in 39.2% of the patients. Median (interquartile range) total SMMSE scores were significantly higher in patients aged </=60 than >60 years (27.0 (2.0) vs. 25.0 (5.0), p=0.000). Multivariate linear regression analyses revealed female gender (B, -1.27; 95% CI, -2.36 to -0.18; p=0.023) and aging (B, -0.20; 95% CI, -0.26 to -0.14; p<0.001) to result in a significant decrease in the total SMMSE scores.

CONCLUSION

Mild-to-moderate cognitive impairment was observed in 39.2% of internal medicine outpatients. Old age and female gender were significant predictors of lower total SMMSE scores. Furthermore, besides for high language scores in hypertensive patients on combined therapy, no significant impact of hypertension or obesity was observed on the SMMSE scores.

Severe Impairment Rating Scale: A Useful and Brief Cognitive Assessment Tool for Advanced Dementia for Nursing Home Residents

To investigate the utility of the Severe Impairment Rating Scale (SIRS) as a cognitive assessment tool among nursing home residents with advanced dementia, we conducted a cross-sectional study of 96 residents in 3 nursing homes with Functional Assessment Staging Test (FAST) stage 6a and above. We compared the discriminatory ability of SIRS with the Chinese version of Mini-Mental State Examination, Abbreviated Mental Test, and Clock Drawing Test. Among the cognitive tests, SIRS showed the least "floor" effect and had the best capacity to distinguish very severe (FAST stages 7d-f) dementia (area under the curve 0.80 vs 0.46-0.76 for the other tools). The SIRS had the best correlation with FAST staging (r = -.59, P < .01) and, unlike the other 3 tools, exhibited only minimal change in correlation when adjusted for education and ethnicity. Our results support the utility of SIRS as a brief cognitive assessment tool for advanced dementia in the nursing home setting.

Re-assessing the dimensional structure of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): empirical evidence for a shortened Brazilian version

BACKGROUND

The dimensional structure, effective number of item responses and item redundancies are controversial features of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) requiring more light. The aims of the present study are to revisit the dimensional structure and propose a shorter version of the instrument.

METHODS

The sample comprised 652 elderly and their informants, either attending a geriatric service of a public university clinic or enrolled in a health care provider database in Rio de Janeiro, Brazil. A Confirmatory Factor Analysis (CFA) first tested the originally proposed one-dimensional structure comprised of 26 items. This was followed by sequential Exploratory Structural Equation Model (ESEM) to evaluate alternative models, in particular a bi-dimensional solution. The identification of residual correlations (RC) lead to a shortened 20-item model, which was tested further via CFA.

RESULTS

The original model fitted poorly (RMSEA = 0.073; 90% CI: 0.069-0.077). Regarding the two-dimensional model, the exploratory procedure (ESEM) indicated several RCs and a lack of factor-based discriminant validity. The ensuing CFA on the one-dimensional model with freely estimated RCs showed an adequate fit (RMSEA = 0.051; 90% CI: 0.047-0.055). Addressing the identified RCs, the CFA on the abridged 20-item version also showed an adequate fit (RMSEA = 0.058; 90% CI: 0.053-0.064) and no further RCs.

CONCLUSION

A one-factor dimensional structure and a reduced version with 20 locally independent items were the most tenable solution. However, although promising, this simpler structure requires further examination before it may be fully supported and recommended.

Culture as a variable in neuroscience and clinical neuropsychology: A comprehensive review

Culture is a dynamic system of bidirectional influences among individuals and their environment, including psychological and biological processes, which facilitate adaptation and social interaction. One of the main challenges in clinical neuropsychology involves cognitive, behavioral and functional assessment of people with different sociocultural backgrounds. In this review essay, examining culture from a historical perspective to ethical issues in cross-cultural research, including the latest significant and publications, the authors sought to explore the main features related to cultural variables in neuropsychological practice and to debate the challenges found regarding the operational methods currently in use. Literature findings suggest a more comprehensive approach in cognitive and behavioral neuroscience, including an interface between elementary disciplines and applied neuropsychology. Thus, as a basis for discussion on this issue, the authors analyzed key-topics related to the study of new trends in sociocultural neuroscience and the application of their concepts from a clinical perspective.

Is there correlation between cognition and functionality in severe dementia? the value of a performance-based ecological assessment for Alzheimer's disease

OBJECTIVE

Besides significant cognitive decline, patients in later stages of Alzheimer's disease (AD) also present global functional impairment, usually reported by their caregivers. This study searched for preserved activities of daily living by investigating correlations among specific instruments for severe dementia with a performance-based functional scale.

METHOD

A sample of 95 moderate to severe AD patients and their caregivers underwent a neuropsychological battery consisting of screening tools, the Functional Assessment Staging Test (FAST), the Severe Mini-Mental State Examination (MMSEsev) and a performance-based ecological scale, the Performance Test of Activities of Daily Living (PADL).

RESULTS

Consistent findings emerged from the comparisons among tests. PADL showed significant statistical correlation with MMSEsev (ρ<0.001), according to FAST subdivisions.

CONCLUSION

Upon suspicion of unreliable caregiver reports, ecological scales may be useful for disease staging. Variable degrees of functionality and cognition may be present even in later stages of AD, requiring proper assessment.