Persistent apathy in Alzheimer's disease as an independent factor of rapid functional decline: the REAL longitudinal cohort study

OBJECTIVE

To determine the role of persistent apathy in rapid loss of autonomy in Instrumental Activities of Daily Living (IADL) in women with Alzheimer s disease (AD), taking into account the grade of cognitive decline.

METHODS

The study was conducted on 272 women from the French REAL cohort. At inclusion patients had a Mini-Mental State Examination (MMSE) score between 10-26. A rapid functional decline was defined as a yearly drop of 4 points or more on the 14-point IADL Lawton scale. Persistent apathy was defined as a frequency score equal to 3 or 4 on the Neuro-Psychiatric Inventory at the three consecutive 6-monthly assessments.

RESULTS

27.6% of women had rapid functional decline in 1 year and 22.1% of them had persistent apathy. A logistic regression analysis showed that, in addition to cognitive decline, persistent apathy plays a role in rapid functional decline in 1 year. For example, for a 3-point decline in MMSE in 1 year, the probability of a rapid loss in IADL is 0.45 for women with persistent apathy compared with 0.28 for those without persistent apathy.

CONCLUSIONS

In this study, a rapid loss in IADL score was partly explained by persistent apathy.

Apathy and depression in Alzheimer's disease are associated with functional deficit and psychotropic prescription

BACKGROUND

Apathy and depression are the most common neuropsychiatric features in Alzheimer's disease (AD). The clinical and functional specific correlates of these syndromes are not well known independently from cognitive deficits and other behavioral disturbances.

MATERIAL AND METHODS

Six hundred and eighty-six patients diagnosed with possible or probable AD were included in a prospective multicenter study (REAL-FR). They had an assessment of their cognitive and functional status. Neuropsychiatric symptoms were assessed with the Neuropsychiatric Inventory (NPI) and caregiver's burden was measured with Zarit's Burden Scale.

RESULTS

A majority of patients at any stage of the disease presented with one or several behavioral and psychological disturbances. Apathy concerned 43% of patients and, with or without depression, was associated with more pronounced deficits in global cognition, everyday life and instrumental abilities, nutritional status and with a higher burden level. A high level of psychotropic prescription, especially with antidepressant, was observed in patients with apathy. In a multivariate analysis taking into account the cognitive and functional variables of AD, apathy and depression were the only significant predictors of psychotropic prescription.

CONCLUSION

Some negative neuropsychiatric symptoms such as apathy and depression have a specific relation with functional and therapeutic outcomes of AD, independently from cognitive status. Further studies are needed to establish if apathy represents a particularly severe phenotype of AD.

[Evaluation of a multifaceted intervention for implementing national guidelines: the case of physical restraint in geriatric care]

BACKGROUND

There is a growing interest in developing guidelines. The French Agency for accreditation and Evaluation (Anaes) published in October 2000 guidelines on the use of restraint in geriatric care settings because in spite of the risks this practice remains widespread in that type of care setting. A multifaceted intervention was conducted in a Parisian geriatric hospital in order to improve the implementation of the published guidelines. An epidemiological study was conducted to assess the outcomes of this intervention.

METHODS

The intervention consisted in distributing educational materials and a specific prescription sheet, and in staff training sessions. A time series study was used to assess outcomes. The three time points were: before the intervention, just after the end of the intervention and one year later. Two dimensions were studied: implementation of the guidelines using markers collected from patients' charts and restraining practices noted in an observational study of hospitalized patients.

RESULTS

The results of the study suggest that five recommendations were followed better: restraint prescription (8.7 to 57.4%), writing in the patient chart the reasons for restraining (3.5 to 35.3%), follow-up prescription, assessment of potential benefits and risks for the patient and patient information (0% to 19-34%). Nevertheless, the prevalence of restraint and of devices employed (around 70%) remained unchanged after the intervention. The various outcomes of the intervention might be explained by the guidelines themselves, which were variably practical or precise. Moreover, the effect of certain factors directly related with the use of restraint, a routine practice strongly supported by myths about its efficacy, as well as factors related to intervention design may merely have prevented any decrease in the use of restraint practices.

CONCLUSION

Multifaceted intervention can favour implementation of certain national guidelines such as prescribing restraint, but can also fail in stimulating the implementation of others such as decreasing the prevalence of restraint in geriatric practice. Therefore the next intervention should emphasize alternatives to physical restraint practices.

IANA (International Academy on Nutrition and Aging) Expert Group: weight loss and Alzheimer's disease

Weight loss, together with psychological and behavioural symptoms and problems of mobility, is one of the principal manifestations of Alzheimer's disease (AD). Weight loss may be associated with protein and energy malnutrition leading to severe complications (alteration of the immune system, muscular atrophy, loss of independence). Various explanations have been proposed such as atrophy of the mesial temporal cortex, biological disturbances, or feeding behaviours; however, none has been proven. Prevention of weight loss in AD is a major issue. It requires regular follow-up and must be an integral part of the care plan. The aim of this article is to review the present state of scientific knowledge on weight loss associated with AD. We will consider four points: the natural history of weight loss, its known etiological factors, its consequences and the various management options.

One-year longitudinal evaluation of neuropsychiatric symptoms in Alzheimer's disease. The REAL.FR Study

Behavioral and Psychological Symptoms are major and frequent manifestations of Alzheimer's Disease (AD). The aim of the present study was to evaluate neuropsychiatric symptoms in the PHRC REAL.FR cohort (for Réseau sur la maladie d'Alzheimer Français) after one year of evolution. Four hundred and eighty two patients with mild and moderate AD were assessed. A majority of them had significant symptoms at inclusion (85.3 % of subjects with mild AD, 89.7% of patients with a moderate AD). Patients with mild AD had a significant increase of the Neuropsychiatric Inventory (NPI) frequency x severity scores for apathy and aberrant motor behavior. Patients with moderate AD had a significant increase of NPI disinhibition, aberrant motor behavior and sleep disorders scores. The variation of NPI total score at one year correlated positively with change in Zarit's caregiver burden score, independently of global cognitive evolution. After one year, a group of 54 patients were institutionalized in nursing home or long term care unit. When compared to non institutionalized patients, the institutionalized group was characterized at base line by a lower MMSE score, a higher Zarit caregiver burden score, and a higher NPI agitation and disinhibition scores.

Predictive factors of rate of loss of autonomy in Alzheimer's disease patients. A prospective study of the REAL.FR Cohort

Alzheimer's disease is characterised by a progressive loss of autonomy in activities of daily living. Many patients lose this autonomy rapidly with dramatic consequences for the patients and their relatives, and for health and social services. The aim of this study was to determine, in a large French cohort of community-living Alzheimer patients (REAL.FR), the factors underpinning different rates of loss of autonomy. Six hundred and eighty seven patients were recruited to this French cohort. Autonomy in activities of daily living was estimated with the IADL scale (Lawton). Patients were divided into three groups according to loss of autonomy during the first one-year follow-up period. Patients with a decrease in the IADL score had worse ADAS-cog score (Alzheimer's Disease Assessment Scale, cognitive subscale), Mini-Mental State Examination (MMSE), and Clinical Dementia Rating Scale scores. Up to a point, a marked decrease in the IADL score was less frequent among patients with a better ADAS-cog score (p < 0.10, bilateral test). At one-year evaluation, patients with a marked decline in autonomy were characterised by a greater decrease in Mini-Mental State score, faster progression of behavioural disturbance, and more hospitalisations. Further prospective studies, using established models, are needed to isolate the factors associated with a high rate of loss of autonomy in activities of daily living in Alzheimer patients.

Démarche diagnostique devant un syndrome démentiel

PURPOSE

The high prevalence of dementia, particularly of Alzheimer's disease, the increase of their incidence with age, and the population aging make this group of diseases a major problem for public health. Nevertheless, diagnosis is difficult because it depends on evolution of disturbances that patients often cannot precisely relate, on complex neuropsychological explorations, and on pathological examination difficult to obtain. Today in France, geriatricians are fully implicated in the diagnosis of dementia and all the physicians who give care to elderly, should lead easily a diagnosis of dementia.

CURRENT KNOWLEDGE AND KEY POINTS

In February 2000 ANAES (French governmental agency for accreditation and evaluation of health system) published recommendations called "practical recommendations for the diagnosis of Alzheimer's disease". These recommendations allow physicians to standardize their practices and consist of a rigorous clinical history and examination, a neuropsychological analysis, standard investigations and application of diagnostic criteria already widely diffused and used.

FUTURE PROSPECTS AND PROJECTS

Deepening of knowledge, in particular in the domains of neuropsychology and functional cerebral imagery, should allow physicians to diagnose early dementia. These early diagnosis should allow to initiate a multidisciplinary, preventive and effective care for patients. Specific drugs, that will be available, will be intended mostly for patients with early diagnosis, ideally at a pre-dementia state.

[Clinical features of ambulatory patients over 80 years of age followed for Alzheimer's disease. French prospective multicenter study REAL.FR]

PURPOSE

Twice out off three, patients with Alzheimer's disease (AD) are aged 80 and older. Very old patients are more frail, have social precariousness and have often polypathology. Few data are available about these elderly patients. The aim of our study was to analyse characteristics of AD patients aged 80 and older.

MATERIAL AND METHODS

This is a prospective, multicentric French study (REAL.FR) of a cohort of ambulatory AD patients, with Mini-Mental State values between 10 and 26. Clinical and social data at inclusion of patients aged 80 and older and patients younger were compared.

RESULTS

Six hundred eighty nine patients (488 women, 201 men) were included between April 2000 and June 2002. The mean age was 77.8 +/- 6.9 years. Two hundred sixty four patients (38%) were aged 80 and older. Those patients were more dependant for Activities of Daily Living (ADL) than younger patients (ADL score of Katz: 5.2 +/- 1.07 et 5.6 +/- 0.74 respectively; p < 0.001 and IADL (Instrumental Activities of Daily Living) score of Lawton: 7.3 +/- 3.57 et 9.3 +/- 1.57 respectively; p < 0.001). Duration of evolution of the disease were comparable between older and younger patients.

CONCLUSION

In our cohort, AD patients aged 80 and older had a weakest autonomy for the ADL than younger patients with the same stage of the disease. Results has implications on care. Following the cohort will permit to specify evolution of data.

Role of behavioural disturbance in the loss of autonomy for activities of daily living in Alzheimer patients

BACKGROUND

Cognitive impairment is associated with functional impairment in patients with Alzheimer's disease (AD). Behavioural disturbance is very common in these patients. Nevertheless, there has been very little research into the relations between behavioural disturbance and functional status in AD. The purpose of this study is to investigate the relationship between behavioural disturbance and functional status after taking account of cognitive impairment.

MATERIAL AND METHODS

579 patients were prospectively evaluated at 16 French hospitals, all referents for AD, and were diagnosed with possible or probable AD. These patients were assessed with NeuroPsychiatric Inventory (NPI), cognitive subscales of the Alzheimer's Disease Assessment Scale (ADAS-cog), Clinical Dementia Rating scale (CDR) and Instrumental Activities of Daily Living scale (IADL).

RESULTS

The number of men with available data for IADL total score was too small to make any analysis. 'Group A' gathered 256 women for whom the relation between autonomy for Activities of Daily Living (ADL) and the other variables were determined. 'Group B', pooled 85 women for whom relations found were verified. Linear regression was used for the analysis. With age, cognitive impairment allows us to explain best (38%) the loss of autonomy for ADL.

CONCLUSION

The role of behavioural disturbances in the loss of autonomy for ADL was not determinant in our study, whereas cognitive impairment and age were better able to determine the loss of autonomy for ADL. Further study is needed to explain the decline of functional status in AD patients.

État nutritionnel et maladie d' Alzheimerrésultats préliminaires de l'étude REAL.FR

Weight loss is common in elderly people with dementia, particularly those with Alzheimer' disease (AD), and feeding difficulties are major issues in their care in the later stages of the disease. In this study (REAL FR for Réseau sur la maladie d'Alzheimer Français) we prospectively used the Mini Nutritional Assessment (MNA) to examine the nutritional status of 479 subjects. Three groups of patients were studied: group 1 = 22 patients with undernutrition (MNA = 17), group 2 = 166 patients with risk of undernutrition (17 < MNA < 24), and group 3 = 291 patients without undernutrition (MNA = 24). Correlations with behavioral and psychological signs and symptoms of dementia (Neuropsychiatric Inventory NPI), with caregiver distress (Zarit), and with the Mini Mental State Examination (MMSE) were studied. Undernutrition is more frequently associated with low MMSE (p < 0.001), high behavioural disturbances (p < 0.001) and high distress of caregivers (p < 0.001). Risk of undernutrition is also associated with NPI (p < 0.001) and Zarit (p < 0.001). These first results in a French cohort of patients with AD underline the importance of the evaluation of nutritional status and finally the follow-up of eating behavior, cognitive status and the quality of life of the caregivers.

Symptômes comportementaux et psychologiques dans la maladied' Alzheimer : résultats de l'étude REAL.FR

Behavioral and Psychological Signs and Symptoms of Dementia (BPSD) are important manifestations of Alzheimer's Disease (AD) and other forms of dementia, because they are associate with care-giver distress, increase the likelihood of institutionalization, and may be associated with more rapid cognitive decline In this study (REAL.FR for Réseau sur la maladie d'Alzheimer Français) we prospectively used the Neuropsychiatric Inventory NPI to examine BPSD. 255 AD patients with a Mini-Mental State Examination (MMSE) score between 11 and 20 and 244 AD patients with a MMSE between 21 and 30 were examined. Factor analysis was carried out leading to three different syndromes according to the level of cognitive impairment. BPSD were detected in 92.5% of the patients with a MMSE between 11 and 20, and in 84% of the patients with a MMSE between 21 and 30. Apathy was the most common abnormality, followed by anxiety and dysphoria. These results in a French cohort of patients with AD underline the importance of the evaluation and finally of the treatment of BPSD.

[Determination of regimen fluindione needed for anticoagulation in the elderly]

INTRODUCTION

There is no validated method to predict the daily maintenance dosage of oral anticoagulation treatment by fluindione in the elderly patients. The aim of our prospective study was to look for a relation between INR at day 2 after a fixed dosage of fluindione and the daily maintenance dosage of fluindione necessary to obtain an INR value between 2 and 3.

PATIENTS AND METHODS

Ten milligrams of fluindione were administered on first and second day of treatment. INR was determined the third day.

RESULTS

From this value, we were able to determine the daily dosage of fluindione (+/- 5mg) that maintained a steady state INR value between 2 and 3.

CONCLUSION

In these very elderly patients, there was a relation between INR at the third day after a fixed dosage of fluindione and the daily maintenance dosage of fluindione necessary to obtain an INR value between 2 and 3.

Does the benefit of antihypertensive treatment outweigh the risk in very elderly hypertensive patients?

The risk of hypertension and the benefits of antihypertensive treatment are well established in older patients aged up to 80 years. For people aged 85 and over, data are scarce and conflicting. A positive association between blood pressure and survival has been found in several cohort studies; this relationship held true after adjustment for many factors in some studies, but disappeared after adjustment for indicators of poor health in others. In randomized trials, the benefit of antihypertensive treatment was demonstrated in the Systolic Hypertension in the Elderly Program (SHEP) study, but it declined with age and was not observable after 80 years in the European Working Party on High Blood Pressure in the Elderly (EWPHE) study. The SYSTolic hypertension in elderly in EURope Trial (SYST-EUR) study evidenced a benefit on cardiovascular morbidity but not on mortality. People who reach a very old age share some characteristics that make them different from those '60 (or 65) and over' and justify special studies which are currently in progress. In the meantime, any treatment decision can only rely on extrapolations moderated by common sense, but the already demonstrated favorable results on morbidity argue against a threshold beyond which hypertension should not be treated.