Alzheimer's disease and other dementias. Implications for physician communication

Methodologies for assessing morphosyntactic ability in people with Alzheimer's disease

BACKGROUND

The detection and description of language impairments in neurodegenerative diseases like Alzheimer's Disease (AD) play an important role in research, clinical diagnosis and intervention. Various methodological protocols have been implemented for the assessment of morphosyntactic abilities in AD; narrative discourse elicitation tasks and structured experimental tasks for production, offline and online structured experimental tasks for comprehension. Very few studies implement and compare different methodological protocols; thus, little is known about the advantages and disadvantages of each methodology.

AIMS

To discuss and compare the main behavioral methodological approaches and tasks that have been used in psycholinguistic research to assess different aspects of morphosyntactic production and comprehension in individuals with AD at the word and sentence levels.

METHODS

A narrative review was conducted through searches in the scientific databases Google Scholar, Scopus, Science Direct, MITCogNet, PubMed. Only studies written in English, that reported quantitative data and were published in peer-reviewed journals were considered with respect to their methodological protocol. Moreover, we considered studies that reported research on all stages of the disease and we included only studies that also reported results of a healthy control group. Studies that implemented standardized assessment tools were not considered in this review.

OUTCOMES & RESULTS

The main narrative discourse elicitation tasks implemented for the assessment of morphosyntactic production include interviews, picture-description and story narration, whereas the main structured experimental tasks include sentence completion, constrained sentence production, sentence repetition and naming. Morphosyntactic comprehension in AD has been assessed with the use of structured experimental tasks, both offline (sentence-picture matching, grammaticality judgment) and online (cross-modal naming,speeded sentence acceptability judgment, auditory moving window, word detection, reading). For each task we considered studies that reported results from different morphosyntactic structures and phenomena in as many different languages as possible.

CONCLUSIONS & IMPLICATIONS

Our review revealed strengths and weaknesses of these methods but also directions for future research. Narrative discourse elicitation tasks as well as structured experimental tasks have been used in a variety of languages, and have uncovered preserved morphosyntactic production but also deficits in people with AD. A combination of narrative discourse elicitation and structured production tasks for the assessment of the same morphosyntactic structure has been rarely used. Regarding comprehension, offline tasks have been implemented in various languages, whereas online tasks have been mainly used in English. Offline and online experimental paradigms have often produced contradictory results even within the same study. The discrepancy between the two paradigms has been attributed to the different working memory demands they impose to the comprehender or to the different parsing processes they tap. Strengths and shortcomings of each methodology are summarized in the paper, and comparisons between different tasks are attempted when this is possible. Thus, the paper may serve as a methodological guide for the study of morphosyntax in AD and possibly in other neurodegenerative diseases.

WHAT THIS PAPER ADDS

What is already known on this subject For the assessment of morphosyntactic abilities in AD, various methodological paradigms have been implemented: narrative discourse elicitation tasks and structured experimental tasks for production, and offline and online structured experimental tasks for comprehension. Very few studies implement and compare different methodological protocols; thus, little is known about the advantages and disadvantages of each methodology. What this paper adds to existing knowledge The paper presents an overview of methodologies that have been used to assess morphosyntactic production and comprehension of people with AD at the word and sentence levels. The paper summarizes the strengths and shortcomings of each methodology, providing both the researcher and the clinician with some directions in their endeavour of investigating language in AD. Also, the paper highlights the need for further research that will implement carefully scrutinized tasks from various experimental paradigms and will explore distinct aspects of the AD patients' morphosyntactic abilities in typologically different languages. What are the potential or actual clinical implications of this work? The paper may serve as a reference point for (psycho-)linguists who wish to study morphosyntactic abilities in AD, and for speech and language therapists who might need to apply morphosyntactic protocols to their patients in order to assess them or design appropriate therapeutic interventions for production and comprehension deficits.

Dementia, Healthcare Decision Making, and Disability Law

Persons with dementia often prefer to participate in decisions about their health care, but may be prevented from doing so because healthcare decision-making law facilitates use of advance directives or surrogate decision makers for persons with decisional impairments such as dementia. Federal and state disability law provide alternative decision-making models that do not prevent persons with mild to moderate dementia from making their own healthcare decisions at the time the decision needs to be made. In order to better promote autonomy and wellbeing, persons with dementia should be accommodated and supported so they can make their own healthcare decisions.

Teeth-derived stem cells: A source for cell therapy

Cell therapy is one of the important therapeutic approaches in the treatment of many diseases such as cancer, degenerative diseases, and cardiovascular diseases. Among various cell types, which could be used as cell therapies, stem cell therapy has emerged as powerful tools in the treatment of several diseases. Multipotent stem cells are one of the main classes of stem cells that could originate from different parts of the body such as bone marrow, adipose, placenta, and tooth. Among several types of multipotent stem cells, tooth-derived stem cells (TDSCs) are associated with special properties such as accessible, easy isolation, and low invasive, which have introduced them as a good source for using in the treatment of several diseases such as neural injuries, liver fibrosis, and Cohrn's disease. Here, we provided an overview of TDSCs particular stem cells from human exfoliated deciduous teeth and clinical application of them. Moreover, we highlighted molecular mechanisms involved in the regulation of dental stem cells fate.

Brazilian transcultural adaptation of an instrument on communicative strategies of caregivers of elderly with dementia

Communication with patients with dementia may be a difficult task for caregivers.

On the early diagnosis of Alzheimer's Disease from multimodal signals: A survey

INTRODUCTION

The number of Alzheimer's Disease (AD) patients is increasing with increased life expectancy and 115.4 million people are expected to be affected in 2050. Unfortunately, AD is commonly diagnosed too late, when irreversible damages have been caused in the patient.

OBJECTIVE

An automatic, continuous and unobtrusive early AD detection method would be required to improve patients' life quality and avoid big healthcare costs. Thus, the objective of this survey is to review the multimodal signals that could be used in the development of such a system, emphasizing on the accuracy that they have shown up to date for AD detection. Some useful tools and specific issues towards this goal will also have to be reviewed.

METHODS

An extensive literature review was performed following a specific search strategy, inclusion criteria, data extraction and quality assessment in the Inspec, Compendex and PubMed databases.

RESULTS

This work reviews the extensive list of psychological, physiological, behavioural and cognitive measurements that could be used for AD detection. The most promising measurements seem to be magnetic resonance imaging (MRI) for AD vs control (CTL) discrimination with an 98.95% accuracy, while electroencephalogram (EEG) shows the best results for mild cognitive impairment (MCI) vs CTL (97.88%) and MCI vs AD distinction (94.05%). Available physiological and behavioural AD datasets are listed, as well as medical imaging analysis steps and neuroimaging processing toolboxes. Some issues such as "label noise" and multi-site data are discussed.

CONCLUSIONS

The development of an unobtrusive and transparent AD detection system should be based on a multimodal system in order to take full advantage of all kinds of symptoms, detect even the smallest changes and combine them, so as to detect AD as early as possible. Such a multimodal system might probably be based on physiological monitoring of MRI or EEG, as well as behavioural measurements like the ones proposed along the article. The mentioned AD datasets and image processing toolboxes are available for their use towards this goal. Issues like "label noise" and multi-site neuroimaging incompatibilities may also have to be overcome, but methods for this purpose are already available.

Estratégias comunicativas de cuidadores de idosos com demência: uma revisão sistemática

RESUMO Objetivo Conduzir uma revisão sistemática de estudos que investigaram estratégias comunicativas utilizadas por cuidadores de idosos com demência, publicados entre 1995 e 2015. Métodos O levantamento de estudos foi feito usando as seguintes palavras-chave “comunicação e cuidador e demência” e “comunicação e cuidador e Alzheimer”, e os termos em inglês “elderspeak and dementia”, “caregiver’s talk and dementia”, “communication and caregiver and dementia” e “communicative and caregiver and Alzheimer”. Desta revisão sistemática, foram excluídos os artigos de intervenção e aqueles que não tinham descrito entre seus objetivos investigar estratégias comunicativas usadas por cuidadores de idosos com demência. Resultados Apenas 22 estudos preencheram os critérios de inclusão. Os estudos revisados mostraram que os cuidadores de idosos com demência utilizam estratégias comunicativas que são ineficazes (por exemplo, comunicação infantilizada; comunicação “controle” e complexa) e eficazes (usar frases simples; dar um comando por vez; realizar perguntas em que a opção de resposta é sim ou não, entre outras). Conclusão É importante avaliar as percepções e avaliações dos cuidadores acerca da eficácia da estratégia utilizada, para que depois sejam ensinadas habilidades de comunicação para cuidadores familiares e cuidadores formais. A comunicação bem-sucedida deve promover a participação dos idosos com demência, contribuindo para manutenção da autonomia e participação tanto dos cuidadores quanto das pessoas acometidas por esse quadro.

Written Education Materials for Stroke Patients and Their Carers: Perspectives and Practices of Health Professionals

Inadequacies in the provision of written education materials to stroke patients and their carers have been reported. In this study, 20 stroke team health professionals were surveyed regarding their use of and perspectives on written education materials. Seventy percent of participants provided materials to 25% or fewer stroke patients and 90% believed that patients and carers are only occasionally or rarely provided with sufficient written information. Health professionals were uncertain which team members provided written information and identified the need to improve the quality of materials used. Stroke teams should implement a system that facilitates the routine provision of quality written materials to patients and carers, communication among team members, and documentation and verbal reinforcement of the information provided.

Aspects of communication in Alzheimer's disease: clinical features and treatment options

BACKGROUND

During the course of Alzheimer's disease (AD), cognitive processes, including language and communication, become increasingly impaired. The aim of this review was to highlight the impact of communication deficits in AD, and discuss the need for effective treatments.

METHOD

PubMed was searched for studies relating to language and communication in AD. The publications identified were used as a basis for the commentary in this paper. Studies relating to the clinical effectiveness of pharmacological treatment for language and communication issues were identified systematically.

RESULTS

Communication deficits are common in AD. From the earliest disease stage, the patient's capacity for communication declines as problems develop with the use of language and all aspects of functional communication. There is a loss of the ability to communicate thoughts and needs, and it becomes increasingly difficult to interact socially and sustain personal relationships with caregivers, family, and friends. It is unsurprising that patients become frustrated at their loss of self-expression, and studies have demonstrated that impaired communication is strongly linked with the development of significant behavioral concerns. Overall, poor communication contributes to caregiver strain, and adds notably to the burden of disease. Clinical data and post-hoc analyses provide preliminary indications that anti-AD therapies (memantine and the cholinesterase inhibitors, ChEIs) and non-pharmacological cognitive-linguistic stimulation techniques may be helpful in addressing communication difficulties.

CONCLUSIONS

The capacity to treat or slow the progression of communication deficits in AD would prolong patient independence, and have a profound impact on the quality of life of patients and caregivers. The use of pharmacological (anti-AD therapies) and non-pharmacological (cognitive-linguistic stimulation) treatments may be useful management methods and warrant further investigation.

Patient-centered communication during the disclosure of a dementia diagnosis

This study examined physician use of patient-centered communication during disclosure of a dementia diagnosis. Fifty-four patients (mean age = 74.13) and companions (mean age = 65.67; n = 34 spouses/partners, 12 adult children, 8 other) were diagnosed with very mild (n = 36) or mild (n = 18) dementia at an Alzheimer's Disease Research Center. Audio recordings of these triadic encounters were evaluated with the Roter Interaction Analysis System. Physicians utilized moderate but variable amounts of patient-centered behaviors including positive rapport building, facilitation, and patient activation (P < .001). Physicians far less frequently used emotional rapport building (P < 0.001). Physicians who demonstrated more patient-centered communication also exhibited greater positive affect (P < 0.05). The use of patient-centered behaviors and positive affect was more variable between physicians than within physicians and may be more dependent on individual physician characteristics than dementia severity or age and gender of patients and companions.

Adherence to medication in patients with dementia: predictors and strategies for improvement

Measures to facilitate patient medication adherence should be considered an integral part of the comprehensive care of older patients with multiple diseases. However, impairment of cognitive functions and dementia, in particular, may substantially compromise adherence behaviour. Therefore, a literature review was performed to identify factors associated with adherence to medication in patients with cognitive impairment or dementia, and to discuss strategies for improvement of non-adherence. Evidence-based information on how to deal with adherence to medication in patients with dementia is scarce because of a lack of specific studies. However, there is increasing knowledge about factors influencing medication adherence behaviour in older age, and emerging insight into the relationships between adherence behaviour and cognitive capacity, memory and executive function, in particular. Nevertheless, understanding elderly persons' strategies for maintaining regular use of even complex drug regimens is still limited. Progress of research in this field is needed. It is notable that measures to improve adherence consist of combinations of educational interventions and cognitive support but assessment of study participants' cognitive function is rare. In clinical practice, awareness of non-adherence as a result of cognitive impairment is relatively low. The most important step is early detection of cognitive impairment when this is impacting negatively on medication management. A practical geriatric screening test is recommended to identify memory problems and further functional impairments associated with cognitive impairment. Performance-based assessments might be useful for screening medication management capacity, in addition to a careful drug history, inspection of all medicines used (including over-the-counter drugs) and proxy information. However, no feasible screening methods have as yet found their way into clinical practice. Patients with impaired executive function, lack of awareness of illness and personality traits such as independency and high self-confidence may be at particular risk of non-adherence. The question is when to switch patient medication self-management to another person's responsibility if cognitive decline progresses. Further research is needed on measures to differentiate cognitive function and the relationships between memory concerns, memory strategy use and medication management. Also, studies evaluating the influence of personal support, health status and depression on the memory strategies used are needed. It is important to assess patients' attitudes toward medication and their relationship with proxies. Strategies for facilitating medication adherence in patients with dementia include prescribing as few medicines as possible, tailoring dose regimens to personal habits, and coordinating all drug dosing schedules as much as possible. When providing medication organizers, it is important to observe the patient's ability to use devices appropriately. In addition, automated computer-based reminding aids, online medication monitoring and telemonitoring may be helpful for patients with mild dementia. The decision as to when assistance with medication self-management is needed has to be made taking into account patient independency and safety aspects. This holds true for medicines with a narrow therapeutic range, in particular. Interactions among the individual patient's cognitive status, mood, level of self-efficacy and particular living situation must also be taken into consideration when searching for the optimal medication adherence strategy. No evidence-based recommendations can be given as yet. However, comprehensive assessment of the individual patient and careful consideration of all potential drug-related problems will probably help facilitate adherence and prevent compromised health outcomes in patients with dementia.