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Mulroy E, Core LB, Chokesuwattanaskul A, Johnson JC, Fletcher PD, Marshall CR, Volkmer A, Rohrer JD, Hardy CJ, Rossor MN, Warren JD. Binary reversals: a diagnostic sign in primary progressive aphasia. J Neurol Neurosurg Psychiatry 2024; 95:477-480. [PMID: 38071563 DOI: 10.1136/jnnp-2023-331662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/08/2023] [Indexed: 02/22/2024]
Abstract
BACKGROUND Binary reversals (exemplified by 'yes'/'no' confusions) have been described in patients with primary progressive aphasia (PPA) but their diagnostic value and phenotypic correlates have not been defined. METHODS We conducted a retrospective cohort study analysing demographic, clinical, neuropsychological, linguistic and behavioural data from patients representing all major PPA syndromes (non-fluent/agrammatic variant, nfvPPA; logopenic variant, lvPPA; semantic variant, svPPA) and behavioural variant frontotemporal dementia (bvFTD). The prevalence of binary reversals and behavioural abnormalities, illness duration, parkinsonian features and neuropsychological test scores were compared between neurodegenerative syndromes, and the diagnostic predictive value of binary reversals was assessed using logistic regression. RESULTS Data were obtained for 83 patients (21 nfvPPA, 13 lvPPA, 22 svPPA, 27 bvFTD). Binary reversals occurred in all patients with nfvPPA, but significantly less frequently and later in lvPPA (54%), svPPA (9%) and bvFTD (44%). Patients with bvFTD with binary reversals had significantly more severe language (but not general executive or behavioural) deficits than those without reversals. Controlling for potentially confounding variables, binary reversals strongly predicted a diagnosis of nfvPPA over other syndromes. CONCLUSIONS Binary reversals are a sensitive (though not specific) neurolinguistic feature of nfvPPA, and should suggest this diagnosis if present as a prominent early symptom.
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Affiliation(s)
- Eoin Mulroy
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Lucy B Core
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Anthipa Chokesuwattanaskul
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
- Division of Neurology, Department of Internal Medicine, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Cognitive Clinical and Computational Neuroscience Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jeremy Cs Johnson
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Phillip D Fletcher
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Charles R Marshall
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
- Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Anna Volkmer
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Jonathan D Rohrer
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Chris Jd Hardy
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Martin N Rossor
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Jason D Warren
- Dementia Research Centre, Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, University College London, London, UK
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Wang J, Huang Y, Bei C, Yang H, Lin Z, Xu L. Causal associations of antioxidants with Alzheimer's disease and cognitive function: a Mendelian randomisation study. J Epidemiol Community Health 2024:jech-2023-221184. [PMID: 38589220 DOI: 10.1136/jech-2023-221184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 03/09/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Circulating antioxidants are associated with a lower risk of Alzheimer's disease (AD) in observational studies, suggesting potential target areas for intervention. However, whether the associations are causal remains unclear. Here, we studied the causality between antioxidants and AD or cognitive function using two-sample Mendelian randomisation (MR). METHODS Single nucleotide polymorphisms strongly (p<5×10-8) associated with antioxidants (vitamin A, vitamin C, zinc, selenium, β-carotene and urate) and outcomes (AD, cognitive performance and reaction time) were obtained from the largest and most recent genome-wide association studies (GWAS). MR inverse variance weighting (IVW) and MR pleiotropy residual sum and outlier test (MR-PRESSO) were used for data analysis. RESULTS Higher genetically determined selenium level was associated with 5% higher risk of AD (OR 1.047, 95% CI 1.005 to 1.091, p=0.028) using IVW. Higher genetically determined urate level was associated with worse cognitive performance (β=-0.026, 95% CI -0.044 to -0.008, p=0.005) using MR-PRESSO. No association between the other antioxidants and AD, cognitive performance and reaction time was found. Similar results were found in the sensitivity analyses. CONCLUSION Our results suggest that lifelong exposure to higher selenium may be associated with a higher risk of AD, and higher urate levels could be associated with worse cognitive performance. Further analyses using larger GWAS of antioxidants are warranted to confirm these observations. Our results suggest that caution is needed in the interpretation of traditional observational evidence on the neuroprotective effects of antioxidants.
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Affiliation(s)
- Jiao Wang
- School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yingyue Huang
- School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chunhua Bei
- School of Public Health, Guilin Medical University, Guilin, Guangxi, China
| | - Huiling Yang
- Eastern-fusion Master Studio of Hezhou, Hezhou, China
| | - Zihong Lin
- Hezhou Research Institute of Longevity Health Science, Hezhou, China
| | - Lin Xu
- School of Public Health, Sun Yat-Sen University, Guangzhou, Guangdong, China
- School of Public Health, The University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, China
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3
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Badenoch JB, Paris A, Jacobs BM, Noyce AJ, Marshall CR, Waters S. Neuroanatomical and prognostic associations of depression in Parkinson's disease. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-333007. [PMID: 38569876 DOI: 10.1136/jnnp-2023-333007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/20/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Depression is reported as a risk factor, prodromal feature and late consequence of Parkinson's disease (PD). We aimed to evaluate the timing, neuroanatomy and prognostic implications of depression in PD. METHODS We used data from 434 023 participants from UK Biobank with 14.1 years of follow-up. Multivariable regression models established associations of depression with incident PD and regional brain volumes. Cox proportional hazards models assessed prognostic associations of depression in PD with incident dementia and all-cause mortality. RESULTS Of 2632 individuals with incident PD, 539 (20.5%) were diagnosed with depression at some point. Depression was associated with an increased risk of subsequent PD (risk ratio 1.53, 95% CI 1.37 to 1.72). Among incident PD cases, depression prevalence rose progressively from 10 years pre-PD diagnosis (OR 2.10, 95% CI 1.57 to 2.83) to 10 years postdiagnosis (OR 3.51, 95% CI 1.33 to 9.22). Depression severity in PD was associated with reduced grey matter volume in structures including the thalamus and amygdala. Depression prior to PD diagnosis increased risk of dementia (HR 1.47, 95% CI 1.05 to 2.07) and mortality (HR 1.30, 95% CI 1.07 to 1.58). CONCLUSIONS This large-scale prospective study demonstrated that depression prevalence increases from 10 years before PD diagnosis and is a marker of cortical and subcortical volume loss. Depression before PD diagnosis signals a worse prognosis in terms of dementia and mortality. This has clinical implications in stratifying people with poorer cognitive and prognostic trajectory in PD.
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Affiliation(s)
- James B Badenoch
- Centre for Preventive Neurology, Queen Mary University of London, London, UK
- Department of Neuroimaging, King's College London Institute of Psychiatry Psychology & Neuroscience, London, UK
| | - Alvar Paris
- Centre for Preventive Neurology, Queen Mary University of London, London, UK
- Neurology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Benjamin Meir Jacobs
- Centre for Preventive Neurology, Queen Mary University of London, London, UK
- Department of Neurology, Barts Health NHS Trust, London, UK
| | - Alastair J Noyce
- Centre for Preventive Neurology, Queen Mary University of London, London, UK
- Department of Neurology, Barts Health NHS Trust, London, UK
| | - Charles R Marshall
- Centre for Preventive Neurology, Queen Mary University of London, London, UK
- Department of Neurology, Barts Health NHS Trust, London, UK
| | - Sheena Waters
- Centre for Preventive Neurology, Queen Mary University of London, London, UK
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4
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Parker TD, Hardy C, Keuss S, Coath W, Cash DM, Lu K, Nicholas JM, James SN, Sudre C, Crutch S, Bamiou DE, Warren JD, Fox NC, Richards M, Schott JM. Peripheral hearing loss at age 70 predicts brain atrophy and associated cognitive change. J Neurol Neurosurg Psychiatry 2024:jnnp-2023-333101. [PMID: 38569877 DOI: 10.1136/jnnp-2023-333101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/04/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Hearing loss has been proposed as a modifiable risk factor for dementia. However, the relationship between hearing, neurodegeneration, and cognitive change, and the extent to which pathological processes such as Alzheimer's disease and cerebrovascular disease influence these relationships, is unclear. METHODS Data from 287 adults born in the same week of 1946 who underwent baseline pure tone audiometry (mean age=70.6 years) and two time point cognitive assessment/multimodal brain imaging (mean interval 2.4 years) were analysed. Hearing impairment at baseline was defined as a pure tone average of greater than 25 decibels in the best hearing ear. Rates of change for whole brain, hippocampal and ventricle volume were estimated from structural MRI using the Boundary Shift Integral. Cognition was assessed using the Pre-clinical Alzheimer's Cognitive Composite. Regression models were performed to evaluate how baseline hearing impairment associated with subsequent brain atrophy and cognitive decline after adjustment for a range of confounders including baseline β-amyloid deposition and white matter hyperintensity volume. RESULTS 111 out of 287 participants had hearing impairment. Compared with those with preserved hearing, hearing impaired individuals had faster rates of whole brain atrophy, and worse hearing (higher pure tone average) predicted faster rates of hippocampal atrophy. In participants with hearing impairment, faster rates of whole brain atrophy predicted greater cognitive change. All observed relationships were independent of β-amyloid deposition and white matter hyperintensity volume. CONCLUSIONS Hearing loss may influence dementia risk via pathways distinct from those typically implicated in Alzheimer's and cerebrovascular disease in cognitively unimpaired older adults.
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Affiliation(s)
- Thomas D Parker
- Department of Brain Sciences, Imperial College London, London, UK
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
- UK Dementia Research Institute Centre for Care Research and Technology, Imperial College London, London, UK
| | - Chris Hardy
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
| | - Sarah Keuss
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
| | - William Coath
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
| | - David M Cash
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
- UK Dementia Research Institute at UCL, University College London, London, UK
| | - Kirsty Lu
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
| | - Jennifer M Nicholas
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Sarah-Naomi James
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Carole Sudre
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
- Centre for Medical Image Computing, University College London, London, UK
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Sebastian Crutch
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
| | - Doris-Eva Bamiou
- UCL Ear Institute and UCLH Biomedical Research Centre, National Institute for Health Research, University College London, London, UK
| | - Jason D Warren
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
| | - Nick C Fox
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
| | - Marcus Richards
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Jonathan M Schott
- The Dementia Research Centre, Department of Neurodegenerative Disease, University College London, London, UK
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5
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Turner MR. We need to talk about brain donation. Pract Neurol 2024:pn-2024-004102. [PMID: 38499333 DOI: 10.1136/pn-2024-004102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Anderson EL, Davies NM, Korologou-Linden R, Kivimäki M. Dementia prevention: the Mendelian randomisation perspective. J Neurol Neurosurg Psychiatry 2024; 95:384-390. [PMID: 37967935 DOI: 10.1136/jnnp-2023-332293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/25/2023] [Indexed: 11/17/2023]
Abstract
Understanding the causes of Alzheimer's disease and related dementias remains a challenge. Observational studies investigating dementia risk factors are limited by the pervasive issues of confounding, reverse causation and selection biases. Conducting randomised controlled trials for dementia prevention is often impractical due to the long prodromal phase and the inability to randomise many potential risk factors. In this essay, we introduce Mendelian randomisation as an alternative approach to examine factors that may prevent or delay Alzheimer's disease. Mendelian randomisation is a causal inference method that has successfully identified risk factors and treatments in various other fields. However, applying this method to dementia risk factors has yielded unexpected findings. Here, we consider five potential explanations and provide recommendations to enhance causal inference from Mendelian randomisation studies on dementia. By employing these strategies, we can better understand factors affecting dementia risk.
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Affiliation(s)
- Emma Louise Anderson
- Mental Health of Older People, Division of Psychiatry, University College London, London, UK
| | - Neil M Davies
- Epidemiology & Applied Clinical Research, Division of Psychiatry, University College London, London, UK
- Department of Statistical Sciences, University College London, London, UK
| | | | - Mika Kivimäki
- Mental Health of Older People, Division of Psychiatry, University College London, London, UK
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7
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Graham N, Zimmerman K, Heslegrave AJ, Keshavan A, Moro F, Abed-Maillard S, Bernini A, Dunet V, Garbero E, Nattino G, Chieregato A, Fainardi E, Baciu C, Gradisek P, Magnoni S, Oddo M, Bertolini G, Schott JM, Zetterberg H, Sharp D. Alzheimer's disease marker phospho-tau181 is not elevated in the first year after moderate-to-severe TBI. J Neurol Neurosurg Psychiatry 2024; 95:356-359. [PMID: 37833041 PMCID: PMC10958285 DOI: 10.1136/jnnp-2023-331854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is associated with the tauopathies Alzheimer's disease and chronic traumatic encephalopathy. Advanced immunoassays show significant elevations in plasma total tau (t-tau) early post-TBI, but concentrations subsequently normalise rapidly. Tau phosphorylated at serine-181 (p-tau181) is a well-validated Alzheimer's disease marker that could potentially seed progressive neurodegeneration. We tested whether post-traumatic p-tau181 concentrations are elevated and relate to progressive brain atrophy. METHODS Plasma p-tau181 and other post-traumatic biomarkers, including total-tau (t-tau), neurofilament light (NfL), ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) and glial fibrillary acidic protein (GFAP), were assessed after moderate-to-severe TBI in the BIO-AX-TBI cohort (first sample mean 2.7 days, second sample within 10 days, then 6 weeks, 6 months and 12 months, n=42). Brain atrophy rates were assessed in aligned serial MRI (n=40). Concentrations were compared patients with and without Alzheimer's disease, with healthy controls. RESULTS Plasma p-tau181 concentrations were significantly raised in patients with Alzheimer's disease but not after TBI, where concentrations were non-elevated, and remained stable over one year. P-tau181 after TBI was not predictive of brain atrophy rates in either grey or white matter. In contrast, substantial trauma-associated elevations in t-tau, NfL, GFAP and UCH-L1 were seen, with concentrations of NfL and t-tau predictive of brain atrophy rates. CONCLUSIONS Plasma p-tau181 is not significantly elevated during the first year after moderate-to-severe TBI and levels do not relate to neuroimaging measures of neurodegeneration.
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Affiliation(s)
- Neil Graham
- Brain Sciences, Imperial College London, London, UK
- UK Dementia Research Institute Centre for Care Research and Technology, Imperial College London, London, UK
| | - Karl Zimmerman
- Brain Sciences, Imperial College London, London, UK
- UK Dementia Research Institute Centre for Care Research and Technology, Imperial College London, London, UK
| | | | - Ashvini Keshavan
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Federico Moro
- Laboratory of Acute Brain Injury and Neuroprotection, Department of Acute Brain and Cardiovascular Injury, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
- Dipartimento di Anestesia e Rianimazione, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Samia Abed-Maillard
- Neuroscience Critical Care Research Group, Department of Intensive Care Medicine, CHUV Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Adriano Bernini
- Department of Clinical Neurosciences, CHUV Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Vincent Dunet
- Department of Medical Radiology, CHUV Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Elena Garbero
- Laboratory of Clinical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Giovanni Nattino
- Laboratory of Clinical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Arturo Chieregato
- Terapia Intensiva ad indirizzo Neurologico & Neurochirurgico, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Enrico Fainardi
- Department of Experimental and Clinical Sciences, Careggi University Hospital and University of Firenze, Florence, Italy
| | - Camelia Baciu
- Terapia Intensiva ad indirizzo Neurologico & Neurochirurgico, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Primoz Gradisek
- Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Center, Ljubljana, Slovenia
| | - Sandra Magnoni
- Department of Anesthesia and Intensive Care, Santa Chiara Hospital, Trento, Italy
| | - Mauro Oddo
- Neuroscience Critical Care Research Group, Department of Intensive Care Medicine, CHUV Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Directorate for Innovation and Clinical Research, CHUV Lausanne University Hospital, Lausanne, Switzerland
| | - Guido Bertolini
- Laboratory of Clinical Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Jonathan M Schott
- UK Dementia Research Institute, University College London, London, UK
- Dementia Research Centre and Department of Neurodegenerative Disease, UCL Queen Square Institute of Neurology, London, UK
| | - Henrik Zetterberg
- UK Dementia Research Institute, University College London, London, UK
- Department of Psychiatry and Neurochemistry, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - David Sharp
- Brain Sciences, Imperial College London, London, UK
- UK Dementia Research Institute Centre for Care Research and Technology, Imperial College London, London, UK
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Parikh NS, Wahbeh F, Tapia C, Ianelli M, Liao V, Jaywant A, Kamel H, Kumar S, Iadecola C. Cognitive impairment and liver fibrosis in non-alcoholic fatty liver disease. BMJ Neurol Open 2024; 6:e000543. [PMID: 38268753 PMCID: PMC10806883 DOI: 10.1136/bmjno-2023-000543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/20/2023] [Indexed: 01/26/2024] Open
Abstract
Background Data regarding the prevalence and phenotype of cognitive impairment in non-alcoholic fatty liver disease (NAFLD) are limited. Objective We assessed the prevalence and nature of cognitive deficits in people with NAFLD and assessed whether liver fibrosis, an important determinant of outcomes in NAFLD, is associated with worse cognitive performance. Methods We performed a prospective cross-sectional study. Patients with NAFLD underwent liver fibrosis assessment with transient elastography and the following assessments: Cognitive Change Index, Eight-Item Informant Interview to Differentiate Aging and Dementia Questionnaire (AD8), Montreal Cognitive Assessment (MoCA), EncephalApp minimal hepatic encephalopathy test and a limited National Institutes of Health Toolbox battery (Flanker Inhibitory Control and Attention Test, Pattern Comparison Test and Auditory Verbal Learning Test). We used multiple linear regression models to examine the association between liver fibrosis and cognitive measures while adjusting for relevant covariates. Results We included 69 participants with mean age 50.4 years (SD 14.4); 62% were women. The median liver stiffness was 5.0 kilopascals (IQR 4.0-6.9), and 25% had liver fibrosis (≥7.0 kilopascals). Cognitive deficits were common in people with NAFLD; 41% had subjective cognitive impairment, 13% had an AD8 >2, 32% had MoCA <26 and 12% had encephalopathy detected on the EncephalApp test. In adjusted models, people with liver fibrosis had modestly worse performance only on the Flanker Inhibitory Control and Attention Task (β=-0.3; 95% CI -0.6 to -0.1). Conclusion Cognitive deficits are common in people with NAFLD, among whom liver fibrosis was modestly associated with worse inhibitory control and attention.
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Affiliation(s)
- Neal S Parikh
- Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Farah Wahbeh
- Neurology, Weill Cornell Medicine, New York, New York, USA
| | | | | | - Vanessa Liao
- Neurology, Weill Cornell Medicine, New York, New York, USA
| | | | - Hooman Kamel
- Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Sonal Kumar
- Medicine, Weill Cornell Medicine, New York, New York, USA
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9
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Pressman PS, Montembeault M, Matthewson G, Lemieux E, Brusilovsky J, Miller BL, Gorno-Tempini ML, Rankin K, Levenson RW. Conversational turn-taking in frontotemporal dementia and related disorders. J Neurol Neurosurg Psychiatry 2024; 95:197-198. [PMID: 37802638 PMCID: PMC10843648 DOI: 10.1136/jnnp-2023-331389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/17/2023] [Indexed: 10/10/2023]
Affiliation(s)
- Peter S Pressman
- Neurology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Maxime Montembeault
- Neurology, University of California Memory and Aging Center, San Francisco, California, USA
- Department of Psychology, McGill University, Montreal, Quebec, Canada
| | - Gordon Matthewson
- Neurology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Eric Lemieux
- Medicine, Baylor University Medical Center, Dallas, Texas, USA
| | - Jane Brusilovsky
- Neurology, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, Colorado, USA
| | - Bruce L Miller
- Memory and Aging Center, University of California Memory and Aging Center, San Francisco, California, USA
| | | | - Katherine Rankin
- Neurology, University of California Memory and Aging Center, San Francisco, California, USA
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Cullinane PW, Wrigley S, Bezerra Parmera J, Valerio F, Millner TO, Shaw K, De Pablo-Fernandez E, Warner TT, Jaunmuktane Z. Pathology of neurodegenerative disease for the general neurologist. Pract Neurol 2023:pn-2023-003988. [PMID: 38124186 DOI: 10.1136/pn-2023-003988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2023] [Indexed: 12/23/2023]
Abstract
Neurodegeneration refers to progressive dysfunction or loss of selectively vulnerable neurones from brain and spinal cord regions. Despite important advances in fluid and imaging biomarkers, the definitive diagnosis of most neurodegenerative diseases still relies on neuropathological examination. Not only has careful clinicopathological correlation shaped current clinical diagnostic criteria and informed our understanding of the natural history of neurodegenerative diseases, but it has also identified conditions with important public health implications, including variant Creutzfeldt-Jakob disease, iatrogenic amyloid-β and chronic traumatic encephalopathy. Neuropathological examination may also point to previously unsuspected genetic diagnoses with potential implications for living relatives. Moreover, detailed neuropathological assessment is crucial for research studies that rely on curated postmortem tissue to investigate the molecular mechanisms responsible for neurodegeneration and for biomarker discovery and validation. This review aims to elucidate the hallmark pathological features of neurodegenerative diseases commonly seen in general neurology clinics, such as Alzheimer's disease and Parkinson's disease; rare but well-known diseases, including progressive supranuclear palsy, corticobasal degeneration and multiple system atrophy and more recently described entities such as chronic traumatic encephalopathy and age-related tau astrogliopathy.
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Affiliation(s)
- Patrick W Cullinane
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, UK
| | - Sarah Wrigley
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, UK
| | - Jacy Bezerra Parmera
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, UK
- Department of Neurology, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Fernanda Valerio
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Thomas O Millner
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Karen Shaw
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, UK
| | - Eduardo De Pablo-Fernandez
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, UK
| | - Thomas T Warner
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, UK
| | - Zane Jaunmuktane
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
- Queen Square Brain Bank for Neurological Disorders, UCL Queen Square Institute of Neurology, London, UK
- Division of Neuropathology, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
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11
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Goldberg TE, Lee S, Devanand DP, Schneider LS. Comparison of relative change with effect size metrics in Alzheimer's disease clinical trials. J Neurol Neurosurg Psychiatry 2023; 95:2-7. [PMID: 37979967 DOI: 10.1136/jnnp-2023-331941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/20/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Per cent slowing of decline is frequently used as a metric of outcome in Alzheimer's disease (AD) clinical trials, but it may be misleading. Our objective was to determine whether per cent slowing of decline or Cohen's d is the more valid and informative measure of efficacy. METHODS Outcome measures of interest were per cent slowing of decline; Cohen's d effect size and number-needed-to-treat (NNT). Data from a graphic were used to model the inter-relationships among Cohen's d, placebo decline in raw score units and per cent slowing of decline with active treatment. NNTs were computed based on different magnitudes of d. Last, we tabulated recent AD anti-amyloid clinical trials that reported per cent slowing and for which we computed their respective d's and NNTs. RESULTS We demonstrated that d and per cent slowing were potentially independent. While per cent slowing of decline was dependent on placebo decline and did not include variance in its computation, d was dependent on both group mean difference and pooled SD. We next showed that d was a critical determinant of NNT, such that NNT was uniformly smaller when d was larger. In recent AD associated trials including those focused on anti-amyloid biologics, d's were below 0.23 and thus considered small, while per cent slowing was in the 22-29% range and NNTs ranged from 14 to 18. CONCLUSIONS Standardised effect size is a more meaningful outcome than per cent slowing of decline because it determines group overlap, which can directly influence NNT computations, and yield information on the likelihood of minimum clinically important differences. In AD, greater use of effect sizes, NNTs, rather than relative per cent slowing, will improve the ability to interpret clinical trial results and evaluate the clinical meaningfulness of statistically significant results.
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Affiliation(s)
- Terry E Goldberg
- Geriatric Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Seonjoo Lee
- Biostatistics, Columbia University Medical Center, New York, New York, USA
- New York State Psychiatric Institute, New York, New York, USA
| | - Davangere P Devanand
- Geriatric Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Lon S Schneider
- Psychiatry and the Behavioral Sciences, USC Keck School of Medicine, Los Angeles, California, USA
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12
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Chun MY, Jang H, Kim SJ, Park YH, Yun J, Lockhart SN, Weiner M, De Carli C, Moon SH, Choi JY, Nam KR, Byun BH, Lim SM, Kim JP, Choe YS, Kim YJ, Na DL, Kim HJ, Seo SW. Emerging role of vascular burden in AT(N) classification in individuals with Alzheimer's and concomitant cerebrovascular burdens. J Neurol Neurosurg Psychiatry 2023; 95:44-51. [PMID: 37558399 PMCID: PMC10803958 DOI: 10.1136/jnnp-2023-331603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/22/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVES Alzheimer's disease (AD) is characterised by amyloid-beta accumulation (A), tau aggregation (T) and neurodegeneration (N). Vascular (V) burden has been found concomitantly with AD pathology and has synergistic effects on cognitive decline with AD biomarkers. We determined whether cognitive trajectories of AT(N) categories differed according to vascular (V) burden. METHODS We prospectively recruited 205 participants and classified them into groups based on the AT(N) system using neuroimaging markers. Abnormal V markers were identified based on the presence of severe white matter hyperintensities. RESULTS In A+ category, compared with the frequency of Alzheimer's pathological change category (A+T-), the frequency of AD category (A+T+) was significantly lower in V+ group (31.8%) than in V- group (64.4%) (p=0.004). Each AT(N) biomarker was predictive of cognitive decline in the V+ group as well as in the V- group (p<0.001). Additionally, the V+ group showed more severe cognitive trajectories than the V- group in the non-Alzheimer's pathological changes (A-T+, A-N+; p=0.002) and Alzheimer's pathological changes (p<0.001) categories. CONCLUSION The distribution and longitudinal outcomes of AT(N) system differed according to vascular burdens, suggesting the importance of incorporating a V biomarker into the AT(N) system.
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Affiliation(s)
- Min Young Chun
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Neurology, Yongin Severance Hospital, Yonsei University Health System, Yongin, South Korea
| | - Hyemin Jang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
- Neuroscience Center, Samsung Medical Center, Seoul, South Korea
- Samsung Alzheimer's Convergence Research Center, Samsung Medical Center, Seoul, South Korea
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Soo-Jong Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
- Neuroscience Center, Samsung Medical Center, Seoul, South Korea
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea
- Department of Intelligent Precision Healthcare Convergence, Sungkyunkwan University, Suwon, South Korea
| | - Yu Hyun Park
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
- Neuroscience Center, Samsung Medical Center, Seoul, South Korea
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea
- Department of Intelligent Precision Healthcare Convergence, Sungkyunkwan University, Suwon, South Korea
| | - Jihwan Yun
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - Samuel N Lockhart
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael Weiner
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA
| | - Charles De Carli
- Department of Neurology, University of California-Davis, Davis, California, USA
| | - Seung Hwan Moon
- Departmentof Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Yong Choi
- Division of Applied RI, Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Kyung Rok Nam
- Division of Applied RI, Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Byung-Hyun Byun
- Department of Nuclear Medicine, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Sang-Moo Lim
- Department of Nuclear Medicine, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, South Korea
| | - Jun Pyo Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
- Neuroscience Center, Samsung Medical Center, Seoul, South Korea
- Samsung Alzheimer's Convergence Research Center, Samsung Medical Center, Seoul, South Korea
- Center for Neuroimaging, Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Yeong Sim Choe
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
| | - Young Ju Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
- Neuroscience Center, Samsung Medical Center, Seoul, South Korea
| | - Duk L Na
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
- Neuroscience Center, Samsung Medical Center, Seoul, South Korea
- Samsung Alzheimer's Convergence Research Center, Samsung Medical Center, Seoul, South Korea
- Cell and Gene Therapy Institute (CGTI), Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Hee Jin Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
- Neuroscience Center, Samsung Medical Center, Seoul, South Korea
- Samsung Alzheimer's Convergence Research Center, Samsung Medical Center, Seoul, South Korea
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea
| | - Sang Won Seo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, South Korea
- Neuroscience Center, Samsung Medical Center, Seoul, South Korea
- Samsung Alzheimer's Convergence Research Center, Samsung Medical Center, Seoul, South Korea
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, South Korea
- Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, South Korea
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13
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Neo S, Kaur J, Ng AS, Lim TC. Elderly woman with psychosis and unsteadiness. Pract Neurol 2023; 23:547-551. [PMID: 37419675 DOI: 10.1136/pn-2023-003731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2023] [Indexed: 07/09/2023]
Affiliation(s)
- Shermyn Neo
- Department of Neurology, National Neuroscience Institute, Singapore
| | | | - Adeline Sl Ng
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Tchoyoson Cc Lim
- Department of Neuroradiology, National Neuroscience Institute, Singapore
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14
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Hu Y. Clustering of morbidities and risk of dementia. J Epidemiol Community Health 2023; 77:685-686. [PMID: 37286347 DOI: 10.1136/jech-2023-220779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 06/09/2023]
Affiliation(s)
- Yaoyue Hu
- School of Public Health, Chongqing Medical University, Chongqing, China
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15
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Banerjee S, Farina N, Henderson C, High J, Stirling S, Shepstone L, Fountain J, Ballard C, Bentham P, Burns A, Fox C, Francis P, Howard R, Knapp M, Leroi I, Livingston G, Nilforooshan R, Nurock S, O'Brien J, Price A, Thomas AJ, Swart AM, Telling T, Tabet N. A pragmatic, multicentre, double-blind, placebo-controlled randomised trial to assess the safety, clinical and cost-effectiveness of mirtazapine and carbamazepine in people with Alzheimer's disease and agitated behaviours: the HTA-SYMBAD trial. Health Technol Assess 2023; 27:1-108. [PMID: 37929672 PMCID: PMC10641860 DOI: 10.3310/vpdt7105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Background Agitation is common and impacts negatively on people with dementia and carers. Non-drug patient-centred care is first-line treatment, but we need other treatment when this fails. Current evidence is sparse on safer and effective alternatives to antipsychotics. Objectives To assess clinical and cost-effectiveness and safety of mirtazapine and carbamazepine in treating agitation in dementia. Design Pragmatic, phase III, multicentre, double-blind, superiority, randomised, placebo-controlled trial of the clinical effectiveness of mirtazapine over 12 weeks (carbamazepine arm discontinued). Setting Twenty-six UK secondary care centres. Participants Eligibility: probable or possible Alzheimer's disease, agitation unresponsive to non-drug treatment, Cohen-Mansfield Agitation Inventory score ≥ 45. Interventions Mirtazapine (target 45 mg), carbamazepine (target 300 mg) and placebo. Outcome measures Primary: Cohen-Mansfield Agitation Inventory score 12 weeks post randomisation. Main economic outcome evaluation: incremental cost per six-point difference in Cohen-Mansfield Agitation Inventory score at 12 weeks, from health and social care system perspective. Data from participants and informants at baseline, 6 and 12 weeks. Long-term follow-up Cohen-Mansfield Agitation Inventory data collected by telephone from informants at 6 and 12 months. Randomisation and blinding Participants allocated 1 : 1 : 1 ratio (to discontinuation of the carbamazepine arm, 1 : 1 thereafter) to receive placebo or carbamazepine or mirtazapine, with treatment as usual. Random allocation was block stratified by centre and residence type with random block lengths of three or six (after discontinuation of carbamazepine, two or four). Double-blind, with drug and placebo identically encapsulated. Referring clinicians, participants, trial management team and research workers who did assessments were masked to group allocation. Results Two hundred and forty-four participants recruited and randomised (102 mirtazapine, 102 placebo, 40 carbamazepine). The carbamazepine arm was discontinued due to slow overall recruitment; carbamazepine/placebo analyses are therefore statistically underpowered and not detailed in the abstract. Mean difference placebo-mirtazapine (-1.74, 95% confidence interval -7.17 to 3.69; p = 0.53). Harms: The number of controls with adverse events (65/102, 64%) was similar to the mirtazapine group (67/102, 66%). However, there were more deaths in the mirtazapine group (n = 7) by week 16 than in the control group (n = 1). Post hoc analysis suggests this was of marginal statistical significance (p = 0.065); this difference did not persist at 6- and 12-month assessments. At 12 weeks, the costs of unpaid care by the dyadic carer were significantly higher in the mirtazapine than placebo group [difference: £1120 (95% confidence interval £56 to £2184)]. In the cost-effectiveness analyses, mean raw and adjusted outcome scores and costs of the complete cases samples showed no differences between groups. Limitations Our study has four important potential limitations: (1) we dropped the proposed carbamazepine group; (2) the trial was not powered to investigate a mortality difference between the groups; (3) recruitment beyond February 2020, was constrained by the COVID-19 pandemic; and (4) generalisability is limited by recruitment of participants from old-age psychiatry services and care homes. Conclusions The data suggest mirtazapine is not clinically or cost-effective (compared to placebo) for agitation in dementia. There is little reason to recommend mirtazapine for people with dementia with agitation. Future work Effective and cost-effective management strategies for agitation in dementia are needed where non-pharmacological approaches are unsuccessful. Study registration This trial is registered as ISRCTN17411897/NCT03031184. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 23. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sube Banerjee
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - Nicolas Farina
- Faculty of Health, University of Plymouth, Plymouth, UK
- Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton and Hove, UK
| | - Catherine Henderson
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Juliet High
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Susan Stirling
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Lee Shepstone
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Julia Fountain
- Coordinator for Service User and Carer Involvement in Research, Sussex Partnership NHS Foundation Trust, Brighton and Hove, UK
| | - Clive Ballard
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health Foundation NHS Trust, Birmingham, UK
| | - Alistair Burns
- Department of Psychiatry, University of Manchester, Manchester, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Paul Francis
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Iracema Leroi
- Department of Psychiatry, Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | - Ramin Nilforooshan
- Research and Development, Surrey and Borders Partnership NHS Foundation Trust, Leatherhead, UK
| | - Shirley Nurock
- Former Carer, Alzheimer's Society Research Network, London, UK
| | - John O'Brien
- Department of Psychiatry, University of Cambridge School of Medicine, Cambridge, UK
| | - Annabel Price
- Cambridgeshire and Peterborough Foundation Trust, Cambridge, UK
| | - Alan J Thomas
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Marie Swart
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, UK
| | - Tanya Telling
- Joint Clinical Research Office, University of Sussex, Brighton, UK
| | - Naji Tabet
- Centre for Dementia Studies, Brighton and Sussex Medical School, University of Sussex, Brighton and Hove, UK
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16
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Georges D, Rakusa E, Holtz AV, Fink A, Doblhammer G. Dementia in Germany: epidemiology, trends and challenges. J Health Monit 2023; 8:30-48. [PMID: 37829121 PMCID: PMC10565880 DOI: 10.25646/11667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/02/2023] [Indexed: 10/14/2023]
Abstract
Background Dementia poses a growing challenge for individuals, healthcare, social support, and society amidst the ongoing ageing of populations. To evaluate the care requirements and social implications of dementia in Germany, reliable statistics regarding its current and future occurrence are necessary. Methods Using existing data sources and recent research results, this paper compiles and analyses relevant statistics on the occurrence of dementia in Germany, presents protective and risk factors, and options for care provision. Results Recent projections indicate a potential surge in the number of dementia patients in Germany, predicted to rise from 1.7 million at present to up to 3.0 million by the year 2070. Cognitive and motor deterioration and behavioural changes associated with dementia lower the ability to live independently. These changes are often tied to social exclusion and stigma and, particularly in the severe phase of the disease, necessitate extensive medical and care requirements. This contributes to dementia being one of the most costly diseases at old age from an overall societal perspective. Currently, there are no curative treatment options available. Conclusions To reduce the increase in the number of dementia patients and associated costs in the future, preventive approaches, particularly promoting a healthy lifestyle, may prove effective. Simultaneously, the healthcare system, society, and caregivers must prepare for the increasing number of dementia patients. Improved diagnostics, new forms of therapy, and social innovations that support those who are affected and their relatives can help reduce the burden of dementia and its associated costs.
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Affiliation(s)
| | - Elena Rakusa
- German Center for Neurodegenerative Diseases, Bonn, Germany
| | | | - Anne Fink
- German Center for Neurodegenerative Diseases, Bonn, Germany
| | - Gabriele Doblhammer
- University Rostock, Germany
- German Center for Neurodegenerative Diseases, Bonn, Germany
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17
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Abe M, Yaguchi H, Kudo A, Nagai A, Shirai S, Takahashi-Iwata I, Matsushima M, Nakamura N, Isahaya K, Yamano Y, Ashida S, Kasai T, Tanaka K, Watanabe M, Kondo T, Takahashi H, Hatakeyama S, Takekoshi A, Kimura A, Shimohata T, Yabe I. Sez6l2 autoimmunity in a large cohort study. J Neurol Neurosurg Psychiatry 2023; 94:667-668. [PMID: 37263766 DOI: 10.1136/jnnp-2022-330194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/04/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Megumi Abe
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroaki Yaguchi
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Akihiko Kudo
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Azusa Nagai
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Shinichi Shirai
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ikuko Takahashi-Iwata
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaaki Matsushima
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoko Nakamura
- Department of Neurology, Mie University Hospital, Tsu, Japan
| | - Kenji Isahaya
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshihisa Yamano
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shinji Ashida
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Kasai
- Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiko Tanaka
- Department of Animal Model Development, Brain Research Institute, Niigata University, Niigata, Japan
| | - Masashi Watanabe
- Department of Biochemistry, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takeshi Kondo
- Department of Biochemistry, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hidehisa Takahashi
- Department of Molecular Biology, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Japan
| | - Shigetsugu Hatakeyama
- Department of Biochemistry, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Akira Takekoshi
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akio Kimura
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ichiro Yabe
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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18
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Wang Q, Zhou S, Zhang J, Wang Q, Hou F, Han X, Shen G, Zhang Y. Risk assessment and stratification of mild cognitive impairment among the Chinese elderly: attention to modifiable risk factors. J Epidemiol Community Health 2023:jech-2022-219952. [PMID: 37321832 DOI: 10.1136/jech-2022-219952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 05/28/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND The early identification of individuals at risk of mild cognitive impairment (MCI) has major public health implications for Alzheimer's disease prevention. OBJECTIVE This study aims to develop and validate a risk assessment tool for MCI with a focus on modifiable factors and a suggested risk stratification strategy. METHODS Modifiable risk factors were selected from recent reviews, and risk scores were obtained from the literature or calculated based on the Rothman-Keller model. Simulated data of 10 000 subjects with the exposure rates of the selected factors were generated, and the risk stratifications were determined by the theoretical incidences of MCI. The performance of the tool was verified using cross-sectional and longitudinal datasets from a population-based Chinese elderly cohort. RESULTS Nine modifiable risk factors (social isolation, less education, hypertension, hyperlipidaemia, diabetes, smoking, drinking, physical inactivity and depression) were selected for the predictive model. The area under the curve (AUC) was 0.71 in the training set and 0.72 in the validation set for the cross-sectional dataset. The AUCs were 0.70 and 0.64 in the training and validation sets, respectively, for the longitudinal dataset. A combined risk score of 0.95 and 1.86 was used as the threshold to categorise MCI risk as 'low', 'moderate' and 'high'. CONCLUSION A risk assessment tool for MCI with appropriate accuracy was developed in this study, and risk stratification thresholds were also suggested. The tool might have significant public health implications for the primary prevention of MCI in elderly individuals in China.
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Affiliation(s)
- Qiong Wang
- School of Health Service Management, Anhui Medical University, Hefei, Anhui, China
| | - Shuai Zhou
- School of Health Service Management, Anhui Medical University, Hefei, Anhui, China
| | - Jingya Zhang
- School of Health Service Management, Anhui Medical University, Hefei, Anhui, China
| | - Qing Wang
- School of Health Service Management, Anhui Medical University, Hefei, Anhui, China
| | - Fangfang Hou
- School of Health Service Management, Anhui Medical University, Hefei, Anhui, China
| | - Xiao Han
- School of Health Service Management, Anhui Medical University, Hefei, Anhui, China
| | - Guodong Shen
- Department of Geriatrics, University of Science and Technology of China, Hefei, Anhui, China
| | - Yan Zhang
- School of Health Service Management, Anhui Medical University, Hefei, Anhui, China
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19
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Khondoker M, Macgregor A, Bachmann MO, Hornberger M, Fox C, Shepstone L. Multimorbidity pattern and risk of dementia in later life: an 11-year follow-up study using a large community cohort and linked electronic health records. J Epidemiol Community Health 2023; 77:285-292. [PMID: 36889910 DOI: 10.1136/jech-2022-220034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/25/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Several long-term chronic illnesses are known to be associated with an increased risk of dementia independently, but little is known how combinations or clusters of potentially interacting chronic conditions may influence the risk of developing dementia. METHODS 447 888 dementia-free participants of the UK Biobank cohort at baseline (2006-2010) were followed-up until 31 May 2020 with a median follow-up duration of 11.3 years to identify incident cases of dementia. Latent class analysis (LCA) was used to identify multimorbidity patterns at baseline and covariate adjusted Cox regression was used to investigate their predictive effects on the risk of developing dementia. Potential effect moderations by C reactive protein (CRP) and Apolipoprotein E (APOE) genotype were assessed via statistical interaction. RESULTS LCA identified four multimorbidity clusters representing Mental health, Cardiometabolic, Inflammatory/autoimmune and Cancer-related pathophysiology, respectively. Estimated HRs suggest that multimorbidity clusters dominated by Mental health (HR=2.12, p<0.001, 95% CI 1.88 to 2.39) and Cardiometabolic conditions (2.02, p<0.001, 1.87 to 2.19) have the highest risk of developing dementia. Risk level for the Inflammatory/autoimmune cluster was intermediate (1.56, p<0.001, 1.37 to 1.78) and that for the Cancer cluster was least pronounced (1.36, p<0.001, 1.17 to 1.57). Contrary to expectation, neither CRP nor APOE genotype was found to moderate the effects of multimorbidity clusters on the risk of dementia. CONCLUSIONS Early identification of older adults at higher risk of accumulating multimorbidity of specific pathophysiology and tailored interventions to prevent or delay the onset of such multimorbidity may help prevention of dementia.
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Affiliation(s)
| | | | - Max O Bachmann
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Lee Shepstone
- Norwich Medical School, University of East Anglia, Norwich, UK
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20
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Barnes RJ, Warren JD. Shouting from far away: three poems about living with speechlessness. Pract Neurol 2023; 23:176-177. [PMID: 36572531 DOI: 10.1136/pn-2022-003651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/27/2022]
Abstract
We present three poems written from personal experience of living with primary progressive non-fluent aphasia (primary progressive apraxia of speech). The poems provide a window on this illness 'from the inside', and vividly illustrate how intellect and inner life may survive strikingly intact, even after speech is lost.
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Affiliation(s)
- Rory Jq Barnes
- Specialist Cognitive Disorders Clinic, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
| | - Jason D Warren
- Dementia Research Centre, UCL Queen Square Institute of Neurology, London, UK
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21
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van 't Hooft JJ, Pelkmans W, Tomassen J, Smits C, Legdeur N, den Braber A, Barkhof F, van Berckel B, Yaqub M, Scheltens P, Pijnenburg YA, Visser PJ, Tijms BM. Distinct disease mechanisms may underlie cognitive decline related to hearing loss in different age groups. J Neurol Neurosurg Psychiatry 2023; 94:314-320. [PMID: 36639225 DOI: 10.1136/jnnp-2022-329726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 11/21/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Hearing loss in older adults is associated with increased dementia risk. Underlying mechanisms that connect hearing loss with dementia remain largely unclear. METHODS We studied the association of hearing loss and biomarkers for dementia risk in two age groups with normal cognition: 65 participants from the European Medical Information Framework (EMIF)-Alzheimer's disease (AD) 90+ study (oldest-old; mean age 92.7 years, 56.9% female) and 60 participants from the EMIF-AD PreclinAD study (younger-old; mean age 74.4, 43.3% female). Hearing function was tested by the 'digits-in-noise test' and cognition by repeated neuropsychological evaluation. Regressions and generalised estimating equations were used to test the association of hearing function and PET-derived amyloid burden, and linear mixed models were used to test the association of hearing function and cognitive decline. In the oldest-old group, mediation analyses were performed to study whether cognitive decline is mediated through regional brain atrophy. RESULTS In oldest-old individuals, hearing function was not associated with amyloid pathology (p=0.7), whereas in the younger-old individuals hearing loss was associated with higher amyloid burden (p=0.0034). In oldest-old individuals, poorer hearing was associated with a steeper decline in memory, global cognition and language, and in the younger-old with steeper decline in language only. The hippocampus and nucleus accumbens mediated the effects of hearing loss on memory and global cognition in the oldest-old individuals. CONCLUSIONS Hearing loss was associated with amyloid binding in younger-old individuals only, and with cognitive decline in both age groups. These results suggest that mechanisms linking hearing loss with risk for dementia depends on age.
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Affiliation(s)
- Jochum J van 't Hooft
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands .,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Wiesje Pelkmans
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Jori Tomassen
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Cas Smits
- Otolaryngology - Head and Neck Surgery, Ear and Hearing, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Nienke Legdeur
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Anouk den Braber
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Department of Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands.,UCL Institutes of Neurology and Healthcare Engineering, University College London, London, UK
| | - Bart van Berckel
- Department of Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Maqsood Yaqub
- Department of Radiology and Nuclear Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Philip Scheltens
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Yolande Al Pijnenburg
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
| | - Pieter Jelle Visser
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands.,Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Alzheimer Center Limburg, Maastricht University, Maastricht, The Netherlands
| | - Betty M Tijms
- Alzheimer Center Amsterdam, Neurology, Vrije Universiteit Amsterdam, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Neurodegeneration, Amsterdam, The Netherlands
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22
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Mitchell JJ, Blodgett JM, Chastin SFM, Jefferis BJ, Wannamethee SG, Hamer M. Exploring the associations of daily movement behaviours and mid-life cognition: a compositional analysis of the 1970 British Cohort Study. J Epidemiol Community Health 2023; 77:189-195. [PMID: 36690475 PMCID: PMC9933163 DOI: 10.1136/jech-2022-219829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/08/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Movement behaviours (eg, sedentary behaviour (SB), moderate and vigorous physical activity (MVPA), light intensity physical activity (LIPA) and sleep) are linked to cognition, yet the relative importance of each component is unclear, and not yet explored with compositional methodologies. OBJECTIVE To (i) assess the associations of different components of daily movement and participant's overall cognition, memory and executive function, and (ii) understand the relative importance of each individual component for cognition. METHODS The 1970 British Cohort Study (BCS70) is a prospective birth cohort study of UK-born adults. At age 46, participants consented to wear an accelerometer device and complete tests of verbal memory and executive function. Compositional linear regression was used to examine cross-sectional associations between 24-hour movement behaviours and standardised cognition scores. Isotemporal substitution was performed to model the effect of reallocating time between components of daily movement on cognition. RESULTS The sample comprised 4481 participants (52% female). Time in MVPA relative to SB, LIPA and sleep was positively associated with cognition after adjustments for education and occupational physical activity, but additional adjustment for health status attenuated associations. SB relative to all other movements was robustly positively associated with cognition. Modelling time reallocation between components revealed an increase in cognition centile after MVPA theoretically replaced 9 min of SB (OR=1.31; 95% CI 0.09 to 2.50), 7 min of LIPA (1.27; 0.07 to 2.46) or 7 min of sleep (1.20; 0.01 to 2.39). CONCLUSIONS Relative to time spent in other behaviours, greater MVPA and SB was associated with higher cognitive scores. Loss of MVPA time, given its smaller relative amount, appears most deleterious. Efforts should be made to preserve MVPA time, or reinforce it in place of other behaviours.
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Affiliation(s)
- John J Mitchell
- Primary Care and Population Health, University College London, London, UK
| | - Joanna M Blodgett
- Institute of Sport, Exercise and Health, University College London, London, UK
| | | | - Barbara J Jefferis
- Primary Care and Population Health, University College London, London, UK
| | - S Goya Wannamethee
- Primary Care and Population Health, University College London, London, UK
| | - Mark Hamer
- Institute of Sport, Exercise and Health, University College London, London, UK
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23
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Mastrangelo A, Mammana A, Baiardi S, Tiple D, Colaizzo E, Rossi M, Vaianella L, Polischi B, Equestre M, Poleggi A, Capellari S, Ladogana A, Parchi P. Evaluation of the impact of CSF prion RT-QuIC and amended criteria on the clinical diagnosis of Creutzfeldt-Jakob disease: a 10-year study in Italy. J Neurol Neurosurg Psychiatry 2023; 94:121-129. [PMID: 36428087 DOI: 10.1136/jnnp-2022-330153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The introduction of the prion Real-Time Quaking-Induced Conversion assay (RT-QuIC) has led to a revision of the diagnostic criteria for sporadic Creutzfeldt-Jakob disease (sCJD).Validation studies are needed for the amended criteria, especially for their diagnostic value in the clinical setting. METHODS We studied 1250 patients with suspected CJD referred for diagnosis to two Italian reference centres between 2010 and 2020. Focusing on the first diagnostic assessment, we compared the diagnostic value of the old and the amended criteria and that of different combinations of clinical variables and biomarker results. RESULTS The studied cohort comprised 850 participants with CJD (297 definite sCJD, 151 genetic CJD, 402 probable sCJD) and 400 with non-CJD (61 with neuropathology). At first clinical evaluation, the sensitivity of the old criteria (76.8%) was significantly lower than that of the amended criteria (97.8%) in the definite CJD cohort with no difference between definite and probable sCJD cases. Specificity was ~94% for both criteria against the non-CJD cohort (82.0% against definite non-CJD group). Cerebrospinal fluid (CSF) RT-QuIC was highly sensitive (93.9%) and fully specific against definite non-CJD patients. Limiting the criteria to a positive RT-QuIC or/and the combination of a clinical course compatible with possible CJD with a positive MRI (Q-CM criteria) provided higher diagnostic accuracy than both the old and amended criteria, overcoming the suboptimal specificity of ancillary test results (ie, CSF protein 14-3-3). CONCLUSIONS CSF RT-QuIC is highly sensitive and specific for diagnosing CJD in vitam. The Q-CM criteria provide a high diagnostic value for CJD.
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Affiliation(s)
- Andrea Mastrangelo
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Angela Mammana
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Simone Baiardi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Dorina Tiple
- Department of Neuroscience, Istituto Superiore di Sanità, Roma, Italy
| | - Elisa Colaizzo
- Department of Neuroscience, Istituto Superiore di Sanità, Roma, Italy
| | - Marcello Rossi
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Luana Vaianella
- Department of Neuroscience, Istituto Superiore di Sanità, Roma, Italy
| | - Barbara Polischi
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Michele Equestre
- Department of Neuroscience, Istituto Superiore di Sanità, Roma, Italy
| | - Anna Poleggi
- Department of Neuroscience, Istituto Superiore di Sanità, Roma, Italy
| | - Sabina Capellari
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Anna Ladogana
- Department of Neuroscience, Istituto Superiore di Sanità, Roma, Italy
| | - Piero Parchi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy .,IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
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24
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Hazan J, Wing M, Liu KY, Reeves S, Howard R. Clinical utility of cerebrospinal fluid biomarkers in the evaluation of cognitive impairment: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2023; 94:113-120. [PMID: 36096664 DOI: 10.1136/jnnp-2022-329530] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/29/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND The analytical and clinical validity of cerebrospinal (CSF) biomarkers has been extensively researched in dementia. Further work is needed to assess the ability of these biomarkers to improve diagnosis, management and health outcomes in the clinical setting OBJECTIVES: To assess the added value and clinical utility of CSF biomarkers in the diagnostic assessment of cognitively impaired patients under evaluation for Alzheimer's disease (AD). METHODS Systematic literature searches of Medline, EMBASE, PsycINFO and Web of Science research databases were conducted on 17 December 2022. Data from relevant studies were extracted and independently screened for quality using a tool for bias. Clinical utility was measured by clinicians' changes in diagnosis, diagnostic confidence and patient management (when available), after their examination of patients' CSF biomarkers. Cost-effectiveness was assessed by consideration of additional cost per patient and quality-adjusted life years. RESULTS Searches identified 17 studies comprising 2090 patient participants and 593 clinicians. The meta-analysis revealed that clinicians' use of CSF biomarkers resulted in a pooled percentage change in diagnosis of 25% (95% CI 14 to 37), an increase in diagnostic confidence of 14% (95% CI 9 to 18) and a pooled proportion of patients whose management changed of 31% (95% CI 12 to 50). CSF biomarkers were deemed cost-effective, particularly in memory services, where pre-test AD prevalence is higher compared with a primary care setting. CONCLUSIONS CSF biomarkers can be a helpful additional diagnostic tool for clinicians assessing patients with cognitive impairment. In particular, CSF biomarkers consistently improved clinicians' confidence in diagnosing AD and influenced on diagnostic change and patient management. Further research is needed to study the clinical utility of blood-based biomarkers in the clinical setting.
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Affiliation(s)
- Jemma Hazan
- Division of Psychiatry, University College London, London, UK
| | - Michelle Wing
- Division of Psychiatry, University College London, London, UK
| | - Kathy Y Liu
- Division of Psychiatry, University College London, London, UK
| | - Suzanne Reeves
- Division of Psychiatry, University College London, London, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
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25
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Carswell C. Idiopathic normal pressure hydrocephalus: historical context and a contemporary guide. Pract Neurol 2023; 23:15-22. [PMID: 36162853 DOI: 10.1136/pn-2021-003291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2022] [Indexed: 02/02/2023]
Abstract
Idiopathic normal pressure hydrocephalus (NPH) was described in 1965 as a syndrome in which hydrocephalus develops but with a normal cerebrospinal fluid (CSF) pressure, causing shunt-responsive gait apraxia, cognitive impairment and urinary incontinence. Not all patients respond to shunting despite having the clinical syndrome with appropriate radiological features. This has led to considerable debate over subsequent decades regarding idiopathic NPH. It is now understood that asymptomatic communicating hydrocephalus can develop in many healthy older people, and that over time this can develop into a symptomatic state that sometimes responds to CSF shunting, but to a variable extent. This review looks at the historical background of NPH, the use of predictive tests, the current state of clinical evidence for the diagnosis and treatment of idiopathic NPH and the possible underlying causes, to provide a contemporary practical guide for assessing patients with the radiological features of idiopathic NPH.
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Affiliation(s)
- Christopher Carswell
- Imperial College Healthcare NHS Trust, London, UK
- Department of Brain Sciences, Imperial College London, London, UK
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26
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Russell ER, Mackay DF, Lyall D, Stewart K, MacLean JA, Robson J, Pell JP, Stewart W. Neurodegenerative disease risk among former international rugby union players. J Neurol Neurosurg Psychiatry 2022; 93:1262-1268. [PMID: 36195436 PMCID: PMC9669247 DOI: 10.1136/jnnp-2022-329675] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/09/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Autopsy studies of former contact sports athletes, including soccer and rugby players, frequently report chronic traumatic encephalopathy, a neurodegenerative pathology associated with traumatic brain injury. Nevertheless, little is known about the risk of neurodegenerative disease in these populations. We hypothesised that neurodegenerative disease risk would be higher among former elite rugby union players than the general population. METHODS We conducted a retrospective cohort study accessing national electronic records on death certification, hospital admissions and dispensed prescriptions for a cohort of 412 male Scottish former international rugby union players and 1236 members of the general population, matched to former players by age, sex and area socioeconomic status. Mortality and incident neurodegenerative disease diagnoses among former rugby players were then compared with the matched comparison group. RESULTS Over a median 32 years follow-up from study entry at age 30 years, 121 (29.4%) former rugby players and 381 (30.8%) of the matched comparison group died. All-cause mortality was lower among former rugby players until 70 years of age with no difference thereafter. During follow-up, 47 (11.4%) former rugby players and 67 (5.4%) of the comparison group were diagnosed with incident neurodegenerative disease (HR 2.67, 95% CI 1.67 to 4.27, p<0.001). CONCLUSIONS This study adds to our understanding of the association between contact sports participation and the risk of neurodegenerative disease. While further research exploring this interaction is required, in the meantime strategies to reduce exposure to head impacts and head injuries in sport should be promoted.
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Affiliation(s)
- Emma R Russell
- School of Psychology and Neuroscience, University of Glasgow, Glasgow, UK
| | - Daniel F Mackay
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Donald Lyall
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Katy Stewart
- Hampden Sports Clinic, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - John A MacLean
- Hampden Sports Clinic, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Jill P Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - William Stewart
- School of Psychology and Neuroscience, University of Glasgow, Glasgow, UK .,Department of Neuropathology, Queen Elizabeth University Hospital, Glasgow, UK
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27
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Schott JM. How preventable is dementia? Pract Neurol 2022; 22:446-447. [PMID: 36008107 DOI: 10.1136/pn-2022-003418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Jonathan M Schott
- Department of Neurodegenerative Diseases, UCL Queen Square Institute of Neurology, London, UK
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28
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Ryan B, To E, Ma'u E, Chan AHY, Rivera-Rodriguez C, Curtis MA, Cullum S, Cheung G. Prevalence of young-onset dementia: nationwide analysis of routinely collected data. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329126. [PMID: 35995550 DOI: 10.1136/jnnp-2022-329126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/23/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Young-onset dementia prevalence is understudied internationally. Previous studies have been limited by low case numbers, reliance on single sources of routinely collected health data for case identification and inclusion of a limited age range. Our objective was to determine the 1-year period prevalence of diagnosed dementia in people aged 0-64 in the entire New Zealand population using routinely collected health data. METHODS A population-based descriptive study was carried out in New Zealand (population 4.8 million) using routinely collected deidentified health data from 2016 to 2020. Dementia cases in seven linked health datasets in the New Zealand Integrated Data Infrastructure were identified using diagnostic codes and/or use of antidementia medication. Prevalence for each of the four study years was calculated by age, sex and ethnicity. RESULTS From a total population of 4 027 332-4 169 754 individuals aged 0-64, we identified 3396-3474 cases of 'all-cause' dementia in each of the study years (prevalence crude range: 83-84/100 000 people aged 0-64; 139-141/100 000 people aged 30-64 years; 204-207/100 000 people aged 45-64 years). Age-standardised prevalence was higher in males than females. Age-standardised and sex-standardised prevalence was higher in Māori and Pacific People than European and Asian. DISCUSSION By using a large study population and multiple national health datasets, we have minimised selection bias and estimated the national prevalence of diagnosed young-onset dementia with precision. Young-onset dementia prevalence for the total New Zealand population was similar to reported global prevalence, validating previous estimates. Prevalence differed by ethnicity, which has important implications for service planning.
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Affiliation(s)
- Brigid Ryan
- Department of Anatomy and Medical Imaging, The University of Auckland, Auckland, New Zealand
| | - Edith To
- Department of Statistics, The University of Auckland, Auckland, New Zealand
| | - Etuini Ma'u
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Amy Hai Yan Chan
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | | | - Maurice A Curtis
- Department of Anatomy and Medical Imaging, The University of Auckland, Auckland, New Zealand
| | - Sarah Cullum
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Gary Cheung
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
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29
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Batty GD, Kaprio J. Traumatic brain injury, collision sports participation, and neurodegenerative disorders: narrative power, scientific evidence, and litigation. J Epidemiol Community Health 2022; 76:jech-2022-219061. [PMID: 35940855 DOI: 10.1136/jech-2022-219061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/20/2022] [Indexed: 12/12/2022]
Affiliation(s)
- G David Batty
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Jaakko Kaprio
- Institute for Molecular Medicine Finland, University of Helsinki, Helsinki, Finland
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30
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Wingo AP, Vattathil SM, Liu J, Fan W, Cutler DJ, Levey AI, Schneider JA, Bennett DA, Wingo TS. LDL cholesterol is associated with higher AD neuropathology burden independent of APOE. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2021-328164. [PMID: 35772923 PMCID: PMC9380478 DOI: 10.1136/jnnp-2021-328164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 06/07/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE APOE is a strong risk factor for Alzheimer's disease (AD) and associated with higher low-density lipoprotein cholesterol (LDL-C) levels. Moreover, LDL-C is associated with the development of clinically ascertained AD; however, whether this association is present with the underlying neuropathological manifestations of AD or whether it is independent of the effect of APOE is unknown and is the focus of this paper. METHODS Individuals in the Religious Orders Study/Memory and Ageing Project cohorts with longitudinal measures of blood lipids and detailed autopsies were studied. We modelled the relationship between blood lipids and 12 age-related brain pathologies using a linear mixed model adjusted for potential confounding factors and stratified by APOE genotype with overall significance determined by meta-analysis. Blood lipids considered were LDL-C, high-density lipoprotein cholesterol and triglycerides. Brain pathologies included AD pathology measured by silver staining (Braak stage, a modified Consortium to Establish a Registry for Alzheimer's Disease [CERAD] score and global AD pathology) and immunohistochemistry (beta-amyloid and neurofibrillary tangles) as well as cerebral microinfarct, cerebral macroinfarct, cerebral amyloid angiopathy, cerebral atherosclerosis, hippocampal sclerosis, TDP-43 cytoplasmic inclusions and Lewy bodies. RESULTS 559 participants (69.1% female) had complete data for analysis. They were followed for a median of 7 years and a median of 3 years prior to dementia onset. LDL-C was associated with all measures of AD neuropathology (neurofibrillary tangles, beta-amyloid, Braak stage, modified CERAD score and global AD pathology) and cerebral amyloid angiopathy independent of APOE after adjusting for age, sex, cholesterol-lowering medication use, body mass index, smoking and education at false discovery rate (FDR) p-value <0.05. CONCLUSIONS These findings implicate LDL-C in the pathophysiology of AD independent of APOE and suggest LDL-C is a modifiable risk factor for AD.
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Affiliation(s)
- Aliza P Wingo
- Division of Mental Health, Atlanta VA Medical Center, Decatur, Georgia, USA
- Department of Psychiatry, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Selina M Vattathil
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jiaqi Liu
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wen Fan
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David J Cutler
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Allan I Levey
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Goizueta Alzheimer's Disease Center, Emory University School of Medicine, Atlanta, GA, USA
| | - Julie A Schneider
- Departments of Pathology and Neurological Science, Rush Alzheimer's Disease Center, Rush University, Chicago, Illinois, USA
- Rush Alzheimer's Disease Center, Rush University, Chicago, Illinois, USA
| | - David A Bennett
- Rush Alzheimer's Disease Center, Rush University, Chicago, Illinois, USA
| | - Thomas S Wingo
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
- Goizueta Alzheimer's Disease Center, Emory University School of Medicine, Atlanta, GA, USA
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31
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Cunningham E. Longest and largest cohort study of delirium to date reinforces association while causation remains elusive. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329266. [PMID: 35697500 DOI: 10.1136/jnnp-2022-329266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 05/26/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Emma Cunningham
- Centre for Public Health, Queen's University Belfast Faculty of Medicine Health and Life Sciences, Belfast, UK
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Leighton SP, Herron JW, Jackson E, Sheridan M, Deligianni F, Cavanagh J. Delirium and the risk of developing dementia: a cohort study of 12 949 patients. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-328903. [PMID: 35606105 PMCID: PMC9304115 DOI: 10.1136/jnnp-2022-328903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/10/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Delirium is an important risk factor for subsequent dementia. However, the field lacks large studies with long-term follow-up of delirium in subjects initially free of dementia to clearly establish clinical trajectories. METHODS We undertook a retrospective cohort study of all patients over the age of 65 diagnosed with an episode of delirium who were initially dementia free at onset of delirium within National Health Service Greater Glasgow & Clyde between 1996 and 2020 using the Safe Haven database. We estimated the cumulative incidence of dementia accounting for the competing risk of death without a dementia diagnosis. We modelled the effects of age at delirium diagnosis, sex and socioeconomic deprivation on the cause-specific hazard of dementia via cox regression. RESULTS 12 949 patients with an incident episode of delirium were included and followed up for an average of 741 days. The estimated cumulative incidence of dementia was 31% by 5 years. The estimated cumulative incidence of the competing risk of death without dementia was 49.2% by 5 years. The cause-specific hazard of dementia was increased with higher levels of deprivation and also with advancing age from 65, plateauing and decreasing from age 90. There did not appear to be a relationship with sex. CONCLUSIONS Our study reinforces the link between delirium and future dementia in a large cohort of patients. It highlights the importance of early recognition of delirium and prevention where possible.
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Affiliation(s)
- Samuel P Leighton
- University of Glasgow, Institute of Health and Wellbeing, Glasgow, Glasgow, UK
| | - James W Herron
- University of Glasgow, Institute of Health and Wellbeing, Glasgow, Glasgow, UK
| | - Eric Jackson
- Imaging Centre of Excellence, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Matthew Sheridan
- Imaging Centre of Excellence, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Fani Deligianni
- University of Glasgow, School of Computing Science, Glasgow, UK
| | - Jonathan Cavanagh
- University of Glasgow, Institute of Infection Immunity and Inflammation, Glasgow, UK
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Mountain G, Wright J, Cooper CL, Lee E, Sprange K, Beresford-Dent J, Young T, Walters S, Berry K, Dening T, Loban A, Turton E, Thomas BD, Young EL, Thompson BJ, Crawford B, Craig C, Bowie P, Moniz-Cook E, Foster A. An intervention to promote self-management, independence and self-efficacy in people with early-stage dementia: the Journeying through Dementia RCT. Health Technol Assess 2022; 26:1-152. [PMID: 35536231 DOI: 10.3310/khha0861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There are few effective interventions for dementia. AIM To determine the clinical effectiveness and cost-effectiveness of an intervention to promote self-management, independence and self-efficacy in people with early-stage dementia. OBJECTIVES To undertake a randomised controlled trial of the Journeying through Dementia intervention compared with usual care, conduct an internal pilot testing feasibility, assess intervention delivery fidelity and undertake a qualitative exploration of participants' experiences. DESIGN A pragmatic two-arm individually randomised trial analysed by intention to treat. PARTICIPANTS A total of 480 people diagnosed with mild dementia, with capacity to make informed decisions, living in the community and not participating in other studies, and 350 supporters whom they identified, from 13 locations in England, took part. INTERVENTION Those randomised to the Journeying through Dementia intervention (n = 241) were invited to take part in 12 weekly facilitated groups and four one-to-one sessions delivered in the community by secondary care staff, in addition to their usual care. The control group (n = 239) received usual care. Usual care included drug treatment, needs assessment and referral to appropriate services. Usual care at each site was recorded. MAIN OUTCOME MEASURES The primary outcome was Dementia-Related Quality of Life score at 8 months post randomisation, with higher scores representing higher quality of life. Secondary outcomes included resource use, psychological well-being, self-management, instrumental activities of daily living and health-related quality of life. RANDOMISATION AND BLINDING Participants were randomised in a 1 : 1 ratio. Staff conducting outcome assessments were blinded. DATA SOURCES Outcome measures were administered in participants' homes at baseline and at 8 and 12 months post randomisation. Interviews were conducted with participants, participating carers and interventionalists. RESULTS The mean Dementia-Related Quality of Life score at 8 months was 93.3 (standard deviation 13.0) in the intervention arm (n = 191) and 91.9 (standard deviation 14.6) in the control arm (n = 197), with a difference in means of 0.9 (95% confidence interval -1.2 to 3.0; p = 0.380) after adjustment for covariates. This effect size (0.9) was less than the 4 points defined as clinically meaningful. For other outcomes, a difference was found only for Diener's Flourishing Scale (adjusted mean difference 1.2, 95% confidence interval 0.1 to 2.3), in favour of the intervention (i.e. in a positive direction). The Journeying through Dementia intervention cost £608 more than usual care (95% confidence interval £105 to £1179) and had negligible difference in quality-adjusted life-years (-0.003, 95% confidence interval -0.044 to 0.038). Therefore, the Journeying through Dementia intervention had a mean incremental cost per quality-adjusted life-year of -£202,857 (95% confidence interval -£534,733 to £483,739); however, there is considerable uncertainty around this. Assessed fidelity was good. Interviewed participants described receiving some benefit and a minority benefited greatly. However, negative aspects were also raised by a minority. Seventeen per cent of participants in the intervention arm and 15% of participants in the control arm experienced at least one serious adverse event. None of the serious adverse events were classified as related to the intervention. LIMITATIONS Study limitations include recruitment of an active population, delivery challenges and limitations of existing outcome measures. CONCLUSIONS The Journeying through Dementia programme is not clinically effective, is unlikely to be cost-effective and cannot be recommended in its existing format. FUTURE WORK Research should focus on the creation of new outcome measures to assess well-being in dementia and on using elements of the intervention, such as enabling enactment in the community. TRIAL REGISTRATION This trial is registered as ISRCTN17993825. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gail Mountain
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Jessica Wright
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Cindy L Cooper
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ellen Lee
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kirsty Sprange
- Nottingham Clinical Trials Research Unit, University of Nottingham, Nottingham, UK
| | | | - Tracey Young
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Stephen Walters
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Katherine Berry
- Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Tom Dening
- Division of Psychiatry & Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Amanda Loban
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emily Turton
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Benjamin D Thomas
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emma L Young
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Benjamin J Thompson
- Sheffield Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Bethany Crawford
- Division of Psychiatry & Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Claire Craig
- Art and Design Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Peter Bowie
- Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | | | - Alexis Foster
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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Gathercole R, Bradley R, Harper E, Davies L, Pank L, Lam N, Davies A, Talbot E, Hooper E, Winson R, Scutt B, Montano VO, Nunn S, Lavelle G, Lariviere M, Hirani S, Brini S, Bateman A, Bentham P, Burns A, Dunk B, Forsyth K, Fox C, Henderson C, Knapp M, Leroi I, Newman S, O'Brien J, Poland F, Woolham J, Gray R, Howard R. Assistive technology and telecare to maintain independent living at home for people with dementia: the ATTILA RCT. Health Technol Assess 2021; 25:1-156. [PMID: 33755548 DOI: 10.3310/hta25190] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Assistive technology and telecare have been promoted to manage the risks associated with independent living for people with dementia, but there is limited evidence of their effectiveness. OBJECTIVES This trial aimed to establish whether or not assistive technology and telecare assessments and interventions extend the time that people with dementia can continue to live independently at home and whether or not they are cost-effective. Caregiver burden, the quality of life of caregivers and of people with dementia and whether or not assistive technology and telecare reduce safety risks were also investigated. DESIGN This was a pragmatic, randomised controlled trial. Blinding was not undertaken as it was not feasible to do so. All consenting participants were included in an intention-to-treat analysis. SETTING This trial was set in 12 councils in England with adult social services responsibilities. PARTICIPANTS Participants were people with dementia living in the community who had an identified need that might benefit from assistive technology and telecare. INTERVENTIONS Participants were randomly assigned to receive either assistive technology and telecare recommended by a health or social care professional to meet their assessed needs (a full assistive technology and telecare package) or a pendant alarm, non-monitored smoke and carbon monoxide detectors and a key safe (a basic assistive technology and telecare package). MAIN OUTCOME MEASURES The primary outcomes were time to admission to care and cost-effectiveness. Secondary outcomes assessed caregivers using the 10-item Center for Epidemiological Studies Depression Scale, the State-Trait Anxiety Inventory 6-item scale and the Zarit Burden Interview. RESULTS Of 495 participants, 248 were randomised to receive full assistive technology and telecare and 247 received the limited control. Comparing the assistive technology and telecare group with the control group, the hazard ratio for institutionalisation was 0.76 (95% confidence interval 0.58 to 1.01; p = 0.054). After adjusting for an imbalance in the baseline activities of daily living score between trial arms, the hazard ratio was 0.84 (95% confidence interval 0.63 to 1.12; p = 0.20). At 104 weeks, there were no significant differences between groups in health and social care resource use costs (intervention group - control group difference: mean -£909, 95% confidence interval -£5336 to £3345) or in societal costs (intervention group - control group difference: mean -£3545; 95% confidence interval -£13,914 to £6581). At 104 weeks, based on quality-adjusted life-years derived from the participant-rated EuroQol-5 Dimensions questionnaire, the intervention group had 0.105 (95% confidence interval -0.204 to -0.007) fewer quality-adjusted life-years than the control group. The number of quality-adjusted life-years derived from the proxy-rated EuroQol-5 Dimensions questionnaire did not differ between groups. Caregiver outcomes did not differ between groups over 24 weeks. LIMITATIONS Compliance with the assigned trial arm was variable, as was the quality of assistive technology and telecare needs assessments. Attrition from assessments led to data loss additional to that attributable to care home admission and censoring events. CONCLUSIONS A full package of assistive technology and telecare did not increase the length of time that participants with dementia remained in the community, and nor did it decrease caregiver burden, depression or anxiety, relative to a basic package of assistive technology and telecare. Use of the full assistive technology and telecare package did not increase participants' health and social care or societal costs. Quality-adjusted life-years based on participants' EuroQol-5 Dimensions questionnaire responses were reduced in the intervention group compared with the control group; groups did not differ in the number of quality-adjusted life-years based on the proxy-rated EuroQol-5 Dimensions questionnaire. FUTURE WORK Future work could examine whether or not improved assessment that is more personalised to an individual is beneficial. TRIAL REGISTRATION Current Controlled Trials ISRCTN86537017. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 19. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Rosie Bradley
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Emma Harper
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Lucy Davies
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Lynn Pank
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Natalie Lam
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Anna Davies
- School of Health Sciences, City, University of London, London, UK.,Population Health Sciences, University of Bristol, Bristol, UK
| | - Emma Talbot
- Norfolk and Suffolk NHS Foundation Trust, Stowmarket, UK
| | - Emma Hooper
- Lancashire Care NHS Foundation Trust, Preston, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Rachel Winson
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Bethany Scutt
- Department of Old Age Psychiatry, King's College London, London, UK
| | | | - Samantha Nunn
- Cambridgeshire Community Services NHS Trust, Cambridge, UK
| | - Grace Lavelle
- Department of Old Age Psychiatry, King's College London, London, UK
| | - Matthew Lariviere
- Centre for International Research on Care, Labour and Equalities, University of Sheffield, Sheffield, UK
| | | | - Stefano Brini
- School of Health Sciences, City, University of London, London, UK
| | - Andrew Bateman
- School of Health and Social Care, University of Essex, Colchester, UK
| | - Peter Bentham
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Alistair Burns
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Barbara Dunk
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Kirsty Forsyth
- School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Catherine Henderson
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Iracema Leroi
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Stanton Newman
- School of Health Sciences, City, University of London, London, UK
| | - John O'Brien
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - John Woolham
- National Institute for Health Research (NIHR) Health & Social Care Workforce Research Unit, King's College London, London, UK
| | - Richard Gray
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Robert Howard
- Division of Psychiatry, University College London, London, UK
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Richardson K, Savva GM, Boyd PJ, Aldus C, Maidment I, Pakpahan E, Loke YK, Arthur A, Steel N, Ballard C, Howard R, Fox C. Non-benzodiazepine hypnotic use for sleep disturbance in people aged over 55 years living with dementia: a series of cohort studies. Health Technol Assess 2021; 25:1-202. [PMID: 33410736 PMCID: PMC7812417 DOI: 10.3310/hta25010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Sleep disturbance affects around 60% of people living with dementia and can negatively affect their quality of life and that of their carers. Hypnotic Z-drugs (zolpidem, zopiclone and zaleplon) are commonly used to treat insomnia, but their safety and efficacy have not been evaluated for people living with dementia. OBJECTIVES To estimate the benefits and harms of Z-drugs in people living with dementia with sleep disturbance. DESIGN A series of observational cohort studies using existing data from (1) primary care linked to hospital admission data and (2) clinical cohort studies of people living with dementia. DATA SOURCES Primary care study - Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality data. Clinical cohort studies - the Resource Use and Disease Course in Dementia - Nursing Homes (REDIC) study, National Alzheimer's Coordinating Centre (NACC) clinical data set and the Improving Well-being and Health for People with Dementia (WHELD) in nursing homes randomised controlled trial. SETTING Primary care study - 371 primary care practices in England. Clinical cohort studies - 47 nursing homes in Norway, 34 Alzheimer's disease centres in the USA and 69 care homes in England. PARTICIPANTS Primary care study - NHS England primary care patients diagnosed with dementia and aged > 55 years, with sleep disturbance or prescribed Z-drugs or low-dose tricyclic antidepressants, followed over 2 years. Clinical cohort studies - people living with dementia consenting to participate, followed over 3 years, 12 years and 9 months, for REDIC, NACC and WHELD, respectively. INTERVENTIONS The primary exposure was prescription or use of Z-drugs. Secondary exposures included prescription or use of benzodiazepines, low-dose tricyclic antidepressants and antipsychotics. MAIN OUTCOME MEASURES Falls, fractures, infection, stroke, venous thromboembolism, mortality, cognitive function and quality of life. There were insufficient data to investigate sleep disturbance. RESULTS The primary care study and combined clinical cohort studies included 6809 and 18,659 people living with dementia, with 3089 and 914 taking Z-drugs, respectively. New Z-drug use was associated with a greater risk of fractures (hazard ratio 1.40, 95% confidence interval 1.01 to 1.94), with risk increasing with greater cumulative dose (p = 0.002). The hazard ratio for Z-drug use and hip fracture was 1.59 (95% confidence interval 1.00 to 2.53) and for mortality was 1.34 (95% confidence interval 1.10 to 1.64). No excess risks of falls, infections, stroke or venous thromboembolism were detected. Z-drug use also did not have an impact on cognition, neuropsychiatric symptoms, disability or quality of life. LIMITATIONS Primary care study - possible residual confounding because of difficulties in identifying patients with sleep disturbance and by dementia severity. Clinical cohort studies - the small numbers of people living with dementia taking Z-drugs and outcomes not necessarily being measured before Z-drug initiation restricted analyses. CONCLUSIONS We observed a dose-dependent increase in fracture risk, but no other harms, with Z-drug use in dementia. However, multiple outcomes were examined, increasing the risk of false-positive findings. The mortality association was unlikely to be causal. Further research is needed to confirm the increased fracture risk. Decisions to prescribe Z-drugs may need to consider the risk of fractures, balanced against the impact of improved sleep for people living with dementia and that of their carers. Our findings suggest that when Z-drugs are prescribed, falls prevention strategies may be needed, and that the prescription should be regularly reviewed. FUTURE WORK More research is needed on safe and effective management strategies for sleep disturbance in people living with dementia. STUDY REGISTRATION This study is registered as European Union electronic Register of Post-Authorisation Studies (EU PAS) 18006. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - George M Savva
- School of Health Sciences, University of East Anglia, Norwich, UK
- Quadram Institute, Norwich, UK
| | - Penelope J Boyd
- School of Health Sciences, University of East Anglia, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Clare Aldus
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Ian Maidment
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Eduwin Pakpahan
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Antony Arthur
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Nicholas Steel
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Robert Howard
- Division of Psychiatry, University College London, London, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
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MacLullich AM, Shenkin SD, Goodacre S, Godfrey M, Hanley J, Stíobhairt A, Lavender E, Boyd J, Stephen J, Weir C, MacRaild A, Steven J, Black P, Diernberger K, Hall P, Tieges Z, Fox C, Anand A, Young J, Siddiqi N, Gray A. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess 2020; 23:1-194. [PMID: 31397263 DOI: 10.3310/hta23400] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Delirium is a common and serious neuropsychiatric syndrome, usually triggered by illness or drugs. It remains underdetected. One reason for this is a lack of brief, pragmatic assessment tools. The 4 'A's test (Arousal, Attention, Abbreviated Mental Test - 4, Acute change) (4AT) is a screening tool designed for routine use. This project evaluated its usability, diagnostic accuracy and cost. METHODS Phase 1 - the usability of the 4AT in routine practice was measured with two surveys and two qualitative studies of health-care professionals, and a review of current clinical use of the 4AT as well as its presence in guidelines and reports. Phase 2 - the 4AT's diagnostic accuracy was assessed in newly admitted acute medical patients aged ≥ 70 years. Its performance was compared with that of the Confusion Assessment Method (CAM; a longer screening tool). The performance of individual 4AT test items was related to cognitive status, length of stay, new institutionalisation, mortality at 12 weeks and outcomes. The method used was a prospective, double-blind diagnostic test accuracy study in emergency departments or in acute general medical wards in three UK sites. Each patient underwent a reference standard delirium assessment and was also randomised to receive an assessment with either the 4AT (n = 421) or the CAM (n = 420). A health economics analysis was also conducted. RESULTS Phase 1 found evidence that delirium awareness is increasing, but also that there is a need for education on delirium in general and on the 4AT in particular. Most users reported that the 4AT was useful, and it was in widespread use both in the UK and beyond. No changes to the 4AT were considered necessary. Phase 2 involved 785 individuals who had data for analysis; their mean age was 81.4 (standard deviation 6.4) years, 45% were male, 99% were white and 9% had a known dementia diagnosis. The 4AT (n = 392) had an area under the receiver operating characteristic curve of 0.90. A positive 4AT score (> 3) had a specificity of 95% [95% confidence interval (CI) 92% to 97%] and a sensitivity of 76% (95% CI 61% to 87%) for reference standard delirium. The CAM (n = 382) had a specificity of 100% (95% CI 98% to 100%) and a sensitivity of 40% (95% CI 26% to 57%) in the subset of participants whom it was possible to assess using this. Patients with positive 4AT scores had longer lengths of stay (median 5 days, interquartile range 2.0-14.0 days) than did those with negative 4AT scores (median 2 days, interquartile range 1.0-6.0 days), and they had a higher 12-week mortality rate (16.1% and 9.2%, respectively). The estimated 12-week costs of an initial inpatient stay for patients with delirium were more than double the costs of an inpatient stay for patients without delirium (e.g. in Scotland, £7559, 95% CI £7362 to £7755, vs. £4215, 95% CI £4175 to £4254). The estimated cost of false-positive cases was £4653, of false-negative cases was £8956, and of a missed diagnosis was £2067. LIMITATIONS Patients were aged ≥ 70 years and were assessed soon after they were admitted, limiting generalisability. The treatment of patients in accordance with reference standard diagnosis limited the ability to assess comparative cost-effectiveness. CONCLUSIONS These findings support the use of the 4AT as a rapid delirium assessment instrument. The 4AT has acceptable diagnostic accuracy for acute older patients aged > 70 years. FUTURE WORK Further research should address the real-world implementation of delirium assessment. The 4AT should be tested in other populations. TRIAL REGISTRATION Current Controlled Trials ISRCTN53388093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 40. See the NIHR Journals Library website for further project information. The funder specified that any new delirium assessment tool should be compared against the CAM, but had no other role in the study design or conduct of the study.
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Affiliation(s)
| | - Susan D Shenkin
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steve Goodacre
- Emergency Medicine, University of Sheffield, Sheffield, UK
| | - Mary Godfrey
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Janet Hanley
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Antaine Stíobhairt
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Elizabeth Lavender
- Health and Social Care, Leeds Institute of Health Sciences, School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Christopher Weir
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Allan MacRaild
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Jill Steven
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Polly Black
- Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Katharina Diernberger
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
| | - Peter Hall
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Zoë Tieges
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Christopher Fox
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Atul Anand
- Geriatric Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - John Young
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Najma Siddiqi
- Psychiatry, University of York, York.,Hull York Medical School, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), NHS Lothian, Edinburgh, UK
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Allan LM, Wheatley A, Smith A, Flynn E, Homer T, Robalino S, Beyer FR, Fox C, Howel D, Barber R, Connolly JA, Robinson L, Parry SW, Rochester L, Corner L, Bamford C. An intervention to improve outcomes of falls in dementia: the DIFRID mixed-methods feasibility study. Health Technol Assess 2020; 23:1-208. [PMID: 31661058 DOI: 10.3310/hta23590] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Fall-related injuries are a significant cause of morbidity and mortality in people with dementia. There is presently little evidence to guide the management of such injuries, and yet there are potentially substantial benefits to be gained if the outcomes of these injuries could be improved. This study aimed to design an appropriate new health-care intervention for people with dementia following a fall and to assess the feasibility of its delivery in the UK NHS. OBJECTIVES To determine whether or not it is possible to design an intervention to improve outcomes of falls in dementia, to investigate the feasibility and acceptability of the DIFRID (Developing an Intervention for Fall related Injuries in Dementia) intervention and to investigate the feasibility of a future randomised controlled trial and the data collection tools needed to evaluate both the effectiveness and the cost-effectiveness of the DIFRID intervention. DESIGN This was a mixed-methods feasibility study. A systematic review (using Cochrane methodology) and realist review [using Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) methodology] explored the existing evidence base and developed programme theories. Searches were carried out in November 2015 (updated in January 2018) for effectiveness studies and in August 2016 for economic studies. A prospective observational study identified service use via participant diary completion. Qualitative methods (semistructured interviews, focus groups and observation) were used to explore current practice, stakeholder perspectives of the health and social care needs of people with dementia following a fall, ideas for intervention and barriers to and facilitators of change. Each of the resulting data sets informed intervention development via Delphi consensus methods. Finally, a single-arm feasibility study with embedded process evaluation was conducted. SETTING This study was set in the community. PARTICIPANTS The participants were (1) people with dementia presenting with falls necessitating health-care attention in each setting (primary care, the community and secondary care) at three sites and their carers, (2) professionals delivering the intervention, who were responsible for training and supervision and who were members of the intervention team, (3) professionals responsible for approaching and recruiting participants and (4) carers of participants with dementia. INTERVENTIONS This was a complex multidisciplinary therapy intervention. Physiotherapists, occupational therapists and support workers delivered up to 22 sessions of tailored activities in the home or local area of the person with dementia over a period of 12 weeks. MAIN OUTCOME MEASURES (1) Assessment of feasibility of study procedures; (2) assessment of the acceptability, feasibility and fidelity of intervention components; and (3) assessment of the suitability and acceptability of outcome measures for people with dementia and their carers (number of falls, quality of life, fear of falling, activities of daily living, goal-setting, health-care utilisation and carer burden). RESULTS A multidisciplinary intervention delivered in the homes of people with dementia was designed based on qualitative work, realist review and recommendations of the consensus panel. The intervention was delivered to 11 people with dementia. The study suggested that the intervention is both feasible and acceptable to stakeholders. A number of modifications were recommended to address some of the issues arising during feasibility testing. The measurement of outcome measures was successful. CONCLUSIONS The study has highlighted the feasibility of delivering a creative, tailored, individual approach to intervention for people with dementia following a fall. Although the intervention required greater investment of time than usual practice, many staff valued the opportunity to work more closely with people with dementia and their carers. We conclude that further research is now needed to refine this intervention in the context of a pilot randomised controlled trial. TRIAL REGISTRATION Current Controlled Trials ISRCTN41760734 and PROSPERO CRD42016029565. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 59. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Louise M Allan
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Alison Wheatley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Amy Smith
- Department of Occupational Therapy, Tees, Esk and Wear Valleys NHS Foundation Trust, Stockton-on-Tees, UK
| | - Elizabeth Flynn
- Department of Physiotherapy, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tara Homer
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Shannon Robalino
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona R Beyer
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Denise Howel
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Robert Barber
- Department of Old Age Psychiatry, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jim Anthony Connolly
- Department of Emergency Medicine, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Louise Robinson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Steve Wayne Parry
- Falls and Syncope Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Lynn Rochester
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Lynne Corner
- VOICE, Newcastle University, Newcastle upon Tyne, UK
| | - Claire Bamford
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Abstract
Dopamine receptor-blocking antipsychotics, first introduced into clinical practice in 1952, were hailed as a panacea in the treatment of a number of psychiatric disorders. However, within 5 years, this notion was to be shattered by the recognition of both acute and chronic drug-induced movement disorders which can accompany their administration. Tardive syndromes, denoting the delayed onset of movement disorders following administration of dopamine receptor-blocking (and also other) drugs, have diverse manifestations ranging from the classic oro-bucco-lingual dyskinesia, through dystonic craniocervical and trunk posturing, to abnormal breathing patterns. Although tardive syndromes have been an important part of movement disorder clinical practice for over 60 years, their pathophysiologic basis remains poorly understood and the optimal treatment approach remains unclear. This review summarises the current knowledge relating to these syndromes and provides clinicians with pragmatic, clinically focused guidance to their management.
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Affiliation(s)
- Eoin Mulroy
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
| | - Bettina Balint
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK.,Department of Neurology, University Hospital, Heidelberg, Germany
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, UK
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Williams T, Houlden H, Murphy E, John N, Fox NC, Schott JM, Adams M, Davagananam I, Chataway J, Lynch DS. How to diagnose difficult white matter disorders. Pract Neurol 2020; 20:280-286. [PMID: 32434903 DOI: 10.1136/practneurol-2020-002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2020] [Indexed: 11/04/2022]
Abstract
Genetic and acquired disorders of white matter comprise a diverse group of conditions, with often overlapping clinical and radiological findings. Patients present with a variable combination of cognitive impairment, ataxia, spasticity or movement disorders, among others. There are many genetic causes, and the route to diagnosis involves comprehensive clinical assessment, radiological expertise, metabolic investigations and finally genetic studies. It is essential not to miss the treatable acquired causes. In this review, we present a practical approach to investigating patients with acquired and genetic disorders of white matter, based on the experience of a large international referral centre. We present a guide for clinicians, including pitfalls of testing, clinical pearls and where to seek advice.
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Affiliation(s)
- Thomas Williams
- Queen Square MS Centre, Department of Neuroinflammation, UCL Institute of Neurology, London, UK
| | - Henry Houlden
- Department of Neuromuscular Disease, UCL Institute of Neurology and the National Hospital for Neurology & Neurosurgery, London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Nevin John
- Queen Square MS Centre, Department of Neuroinflammation, UCL Institute of Neurology, London, UK
| | - Nick C Fox
- Dementia Research Centre, Department of Neurodegenerative Disease, University College London, Queen Square Institute of Neurology, London, UK
| | - Jonathan M Schott
- Dementia Research Centre, Department of Neurodegenerative Disease, University College London, Queen Square Institute of Neurology, London, UK
| | - Matthew Adams
- Lysholm Department of Neuroradiology, National Hospital for Neurology & Neurosurgery, London, UK
| | - Indran Davagananam
- Lysholm Department of Neuroradiology, National Hospital for Neurology & Neurosurgery, London, UK.,Department of Brain Repair and Rehabilitation (ID), UCL Institute of Neurology, London, UK
| | - Jeremy Chataway
- Queen Square MS Centre, Department of Neuroinflammation, UCL Institute of Neurology, London, UK
| | - David S Lynch
- Department of Neuromuscular Disease, UCL Institute of Neurology and the National Hospital for Neurology & Neurosurgery, London, UK
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Surr CA, Holloway I, Walwyn RE, Griffiths AW, Meads D, Kelley R, Martin A, McLellan V, Ballard C, Fossey J, Burnley N, Chenoweth L, Creese B, Downs M, Garrod L, Graham EH, Lilley-Kelley A, McDermid J, Millard H, Perfect D, Robinson L, Robinson O, Shoesmith E, Siddiqi N, Stokes G, Wallace D, Farrin AJ. Dementia Care Mapping™ to reduce agitation in care home residents with dementia: the EPIC cluster RCT. Health Technol Assess 2020; 24:1-172. [PMID: 32216870 PMCID: PMC7132533 DOI: 10.3310/hta24160] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The quality of care for people with dementia in care homes is of concern. Interventions that can improve care outcomes are required. OBJECTIVE To investigate the clinical effectiveness and cost-effectiveness of Dementia Care Mapping™ (DCM) for reducing agitation and improving care outcomes for people living with dementia in care homes, versus usual care. DESIGN A pragmatic, cluster randomised controlled trial with an open-cohort design, follow-up at 6 and 16 months, integrated cost-effectiveness analysis and process evaluation. Clusters were not blinded to allocation. The primary end point was completed by staff proxy and independent assessors. SETTING Stratified randomisation of 50 care homes to the intervention and control groups on a 3 : 2 ratio by type, size, staff exposure to dementia training and recruiting hub. PARTICIPANTS Fifty care homes were randomised (intervention, n = 31; control, n = 19), with 726 residents recruited at baseline and a further 261 recruited after 16 months. Care homes were eligible if they recruited a minimum of 10 residents, were not subject to improvement notices, had not used DCM in the previous 18 months and were not participating in conflicting research. Residents were eligible if they lived there permanently, had a formal diagnosis of dementia or a score of 4+ on the Functional Assessment Staging Test of Alzheimer's Disease, were proficient in English and were not terminally ill or permanently cared for in bed. All homes were audited on the delivery of dementia and person-centred care awareness training. Those not reaching a minimum standard were provided training ahead of randomisation. Eighteen homes took part in the process evaluation. INTERVENTION Two staff members from each intervention home were trained to use DCM and were asked to carry out three DCM cycles; the first was supported by an external expert. MAIN OUTCOME MEASURES The primary outcome was agitation (Cohen-Mansfield Agitation Inventory), measured at 16 months. Secondary outcomes included resident behaviours and quality of life. RESULTS There were 675 residents in the final analysis (intervention, n = 388; control, n = 287). There was no evidence of a difference in agitation levels between the treatment arms. The adjusted mean difference in Cohen-Mansfield Agitation Inventory score was -2.11 points, being lower in the intervention group than in the control (95% confidence interval -4.66 to 0.44; p = 0.104; adjusted intracluster correlation coefficient: control = 0, intervention = 0.001). The sensitivity analyses results supported the primary analysis. No differences were detected in any of the secondary outcomes. The health economic analyses indicated that DCM was not cost-effective. Intervention adherence was problematic; only 26% of homes completed more than their first DCM cycle. Impacts, barriers to and facilitators of DCM implementation were identified. LIMITATIONS The primary completion of resident outcomes was by staff proxy, owing to self-report difficulties for residents with advanced dementia. Clusters were not blinded to allocation, although supportive analyses suggested that any reporting bias was not clinically important. CONCLUSIONS There was no benefit of DCM over control for any outcomes. The implementation of DCM by care home staff was suboptimal compared with the protocol in the majority of homes. FUTURE WORK Alternative models of DCM implementation should be considered that do not rely solely on leadership by care home staff. TRIAL REGISTRATION Current Controlled Trials ISRCTN82288852. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Claire A Surr
- Centre for Dementia Research, School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Ivana Holloway
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | | | - Alys W Griffiths
- Centre for Dementia Research, School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - David Meads
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Rachael Kelley
- Centre for Dementia Research, School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Adam Martin
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Vicki McLellan
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | | | - Jane Fossey
- Psychological Services, Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Natasha Burnley
- Centre for Dementia Research, School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | | | | | - Murna Downs
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Lucy Garrod
- Psychological Services, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Elizabeth H Graham
- Academic Unit of Elderly Care and Rehabilitation, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Joanne McDermid
- Wolfson Centre for Age-Related Diseases, King's College London, London, UK
| | - Holly Millard
- Psychological Services, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Devon Perfect
- Psychological Services, Oxford Health NHS Foundation Trust, Oxford, UK
| | - Louise Robinson
- Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, UK
| | - Olivia Robinson
- Centre for Dementia Research, School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Emily Shoesmith
- Centre for Dementia Research, School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Najma Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | | | - Daphne Wallace
- Centre for Dementia Research, School of Health and Community Studies, Leeds Beckett University, Leeds, UK
| | - Amanda J Farrin
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
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Froggatt K, Best A, Bunn F, Burnside G, Coast J, Dunleavy L, Goodman C, Hardwick B, Jackson C, Kinley J, Davidson Lund A, Lynch J, Mitchell P, Myring G, Patel S, Algorta GP, Preston N, Scott D, Silvera K, Walshe C. A group intervention to improve quality of life for people with advanced dementia living in care homes: the Namaste feasibility cluster RCT. Health Technol Assess 2020; 24:1-140. [PMID: 31971506 PMCID: PMC7008353 DOI: 10.3310/hta24060] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND People with advanced dementia who live and die in nursing homes experience variable quality of life, care and dying. There is a need to identify appropriate, cost-effective interventions that facilitate high-quality end-of-life care provision. OBJECTIVES To establish the feasibility and acceptability to staff and family of conducting a cluster randomised controlled trial of the Namaste Care intervention for people with advanced dementia in nursing homes. DESIGN The study had three phases: (1) realist review and (2) intervention refinement to inform the design of (3) a feasibility cluster randomised controlled trial with a process evaluation and economic analysis. Clusters (nursing homes) were randomised in a 3 : 1 ratio to intervention or control (usual care). The nature of the intervention meant that blinding was not possible. SETTING Nursing homes in England providing care for people with dementia. PARTICIPANTS Residents with advanced dementia (assessed as having a Functional Assessment Staging Test score of 6 or 7), their informal carers and nursing home staff. INTERVENTION Namaste Care is a complex group intervention that provides structured personalised care in a dedicated space, focusing on enhancements to the physical environment, comfort management and sensory engagement. MAIN OUTCOME MEASURES The two contender primary outcome measures were Comfort Assessment in Dying - End of Life Care in Dementia for quality of dying (dementia) and Quality of Life in Late Stage Dementia for quality of life. The secondary outcomes were as follows: person with dementia, sleep/activity (actigraphy), neuropsychiatric symptoms, agitation and pain; informal carers, satisfaction with care at the end of life; staff members, person-centred care assessment, satisfaction with care at the end of life and readiness for change; and other data - health economic outcomes, medication/service use and intervention activity. RESULTS Phase 1 (realist review; 86 papers) identified that a key intervention component was the activities enabling the development of moments of connection. In phase 2, refinement of the intervention enabled the production of a user-friendly 16-page A4 booklet. In phase 3, eight nursing homes were recruited. Two homes withdrew before the intervention commenced; four intervention and two control homes completed the study. Residents with advanced dementia (n = 32) were recruited in intervention (n = 18) and control (n = 14) homes. Informal carers (total, n = 12: intervention, n = 5; control, n = 7) and 97 staff from eight sites (intervention, n = 75; control, n = 22) were recruited over a 6-month period. Recruitment is feasible. Completion rates of the primary outcome questionnaires were high at baseline (100%) and at 4 weeks (96.8%). The Quality of Life in Late Stage Dementia was more responsive to change over 24 weeks. Even where economic data were missing, these could be collected in a full trial. The intervention was acceptable; the dose varied depending on the staffing and physical environment of each care home. Staff and informal carers reported changes for the person with dementia in two ways: increased social engagement and greater calm. No adverse events related to the intervention were reported. CONCLUSIONS A subsequent definitive trial is feasible if there are amendments to the recruitment process, outcome measure choice and intervention specification. FUTURE WORK In a full trial, consideration is needed of the appropriate outcome measure that is sensitive to different participant responses, and of clear implementation principles for this person-centred intervention in a nursing home context. TRIAL REGISTRATION Current Controlled Trials ISRCTN14948133. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Katherine Froggatt
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Ashley Best
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Frances Bunn
- Department of Health and Human Sciences, University of Hertfordshire, Hatfield, UK
| | - Girvan Burnside
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Joanna Coast
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lesley Dunleavy
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Claire Goodman
- Department of Health and Human Sciences, University of Hertfordshire, Hatfield, UK
| | - Ben Hardwick
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Clare Jackson
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | | | | | - Jennifer Lynch
- Department of Health and Human Sciences, University of Hertfordshire, Hatfield, UK
| | - Paul Mitchell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gareth Myring
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shakil Patel
- Lancashire Clinical Trials Unit, University of Central Lancashire, Preston, UK
| | - Guillermo Perez Algorta
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Nancy Preston
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | | | - Kate Silvera
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Catherine Walshe
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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Kenny J, Woollacott I, Koriath C, Hosszu L, Adamson G, Rudge P, Rossor MN, Collinge J, Rohrer JD, Mead S. A novel prion protein variant in a patient with semantic dementia. J Neurol Neurosurg Psychiatry 2017; 88:890-892. [PMID: 28572272 PMCID: PMC5629930 DOI: 10.1136/jnnp-2017-315577] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/13/2017] [Accepted: 03/20/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Joanna Kenny
- MRC Prion Unit, Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,NHS National Prion Clinic, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ione Woollacott
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Carolin Koriath
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Laszlo Hosszu
- MRC Prion Unit, Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Gary Adamson
- MRC Prion Unit, Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Peter Rudge
- NHS National Prion Clinic, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Martin N Rossor
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - John Collinge
- MRC Prion Unit, Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,NHS National Prion Clinic, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jonathan D Rohrer
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Simon Mead
- MRC Prion Unit, Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,NHS National Prion Clinic, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
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Gellersen HM, Guo CC, O'Callaghan C, Tan RH, Sami S, Hornberger M. Cerebellar atrophy in neurodegeneration-a meta-analysis. J Neurol Neurosurg Psychiatry 2017; 88:780-788. [PMID: 28501823 DOI: 10.1136/jnnp-2017-315607] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/23/2017] [Accepted: 04/10/2017] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The cerebellum has strong cortical and subcortical connectivity, but is rarely taken into account for clinical diagnosis in many neurodegenerative conditions, particularly in the absence of clinical ataxia. The current meta-analysis aims to assess patterns of cerebellar grey matter atrophy in seven neurodegenerative conditions (Alzheimer's disease (AD), Parkinson's disease (PD) and Huntington's disease (HD), frontotemporal dementia (FTD), amyotrophic lateral sclerosis (ALS), multiple system atrophy (MSA), progressive supranuclear palsy (MSP)). METHODS We carried out a systematic search in PubMed (any date: 14 July 2016) and a hand search of references from pertinent articles according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors were contacted to provide missing coordinate data. Peer-reviewed studies with direct comparison of patient and control groups, and availability of coordinate data of grey matter cerebellar atrophy in patients were included. These coordinates were used in an anatomical likelihood estimation meta-analysis. RESULTS Across 54 studies, clusters of cerebellar atrophy were found for AD, ALS, FTD, MSA, and PSP. Atrophy patterns were largely disease-specific, with overlap in certain areas of the cerebellar hemisphere, which showed marked atrophy in AD, ALS, FTD and PSP (Crus I/II), and MSA and PSP (lobules I-IV), respectively. Atrophy colocated with cerebellar areas implicated for motor (PSP, MSA) or cognitive symptoms (FTD, ALS, PSP) in the diseases. DISCUSSION Our findings suggest that cerebellar changes are largely disease-specific and correspond to cortical or subcortical changes in neurodegenerative conditions. High clinical variability in PD and HD samples may explain the absence of findings for consistent grey matter loss across studies. Our results have clinical implications for diagnosis and cerebellar neuroimaging referencing approaches.
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Affiliation(s)
- Helena M Gellersen
- Department of Cognitive Neuroscience, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | - Christine C Guo
- Mental Health Program, QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Claire O'Callaghan
- Behavioural and Clinical Neuroscience Institute and Department of Psychology, University of Cambridge, Cambridge, UK.,Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Rachel H Tan
- Brain and Mind Centre, Sydney Medical School, The University of Sydney, Sydney, Australia.,Neuroscience Research Australia, Sydney, Australia
| | - Saber Sami
- Department of Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | - Michael Hornberger
- Norwich Medical School, University of East Anglia, Norwich, UK.,Dementia and Complexity in Later Life, NHS Norfolk and Suffolk Foundation Trust, UK
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Lawson RA, Yarnall AJ, Duncan GW, Breen DP, Khoo TK, Williams-Gray CH, Barker RA, Burn DJ. Stability of mild cognitive impairment in newly diagnosed Parkinson's disease. J Neurol Neurosurg Psychiatry 2017; 88:648-652. [PMID: 28250029 PMCID: PMC5537517 DOI: 10.1136/jnnp-2016-315099] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/12/2016] [Accepted: 12/14/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Mild cognitive impairment (MCI) is common in early Parkinson's disease (PD). We evaluated the stability of PD-MCI over time to determine its clinical utility as a marker of disease. METHODS 212 newly diagnosed participants with PD were recruited into a longitudinal study and reassessed after 18 and 36 months. Participants completed a range of clinical and neuropsychological assessments. PD-MCI was classified using Movement Disorders Society Task Force level I (Montreal Cognitive Assessment <26) and level II (using cut-offs of 1, 1.5 and 2SD) criteria. RESULTS After 36 months, 75% of participants returned; 8% of patients had developed a dementia all of which were previously PD-MCI. Applying level I criteria, 70% were cognitively stable, 19% cognitively declined and 11% improved over 36 months. Applying level II criteria (1, 1.5 and 2SD), 25% were cognitively stable, 41% cognitively declined, 15% improved and 19% fluctuated over 36 months. 18% of participants reverted to normal cognition from PD-MCI. DISCUSSION Cognitive impairment in PD is complex, with some individuals' function fluctuating over time and some reverting to normal cognition. PD-MCI level I criteria may have greater clinical convenience, but more comprehensive level II criteria with 2SD cut-offs may offer greater diagnostic certainty.
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Affiliation(s)
- Rachael A Lawson
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Alison J Yarnall
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Gordon W Duncan
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK.,Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - David P Breen
- John van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK
| | - Tien K Khoo
- School of Medicine & Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia.,School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | | | - Roger A Barker
- John van Geest Centre for Brain Repair, University of Cambridge, Cambridge, UK
| | - David J Burn
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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Abstract
Memantine is an uncompetitive N-methyl-d-aspartate receptor antagonist and probably also has an indirect dopaminergic action at high concentrations. We describe a person with Alzheimer's disease who developed chorea and dystonia after inadvertently doubling of her daily dose by taking extended-release (XR) memantine twice daily, rather than once daily (planned dose memantine XR, 21 mg once daily), after the drug was switched from immediate release (IR, 10 mg twice daily). Memantine is rarely associated with movement disorders, but this case emphasises the need for awareness of potential problems when switching from memantine IR to XR.
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Affiliation(s)
- Letizia Goncalves Borges
- Cognitive Neurology and Alzheimer's Disease Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Borna Bonakdarpour
- Cognitive Neurology and Alzheimer's Disease Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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46
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Poletti M, Cavallo M, Adenzato M. Detecting dysexecutive syndrome in neurodegenerative diseases: are we using an appropriate approach and effective diagnostic tools? J Neurol Neurosurg Psychiatry 2017; 88:195. [PMID: 28213510 DOI: 10.1136/jnnp-2016-314744] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 09/07/2016] [Accepted: 09/20/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Michele Poletti
- Child and Adolescent Psychiatry Unit, Department of Mental Health and Pathological Addiction, Azienda Unità Sanitaria Locale, Reggio Emilia, Italy
| | - Marco Cavallo
- eCampus University, Novedrate, Italy.,Azienda Sanitaria Locale Torino 3, Collegno, Italy
| | - Mauro Adenzato
- Department of Psychology, Center for Cognitive Science, University of Turin, Turin, Italy.,Neuroscience Institute of Turin, Turin, Italy
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47
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Lu H, Lam LCW. Impacts of 'two-level' variability on the differential power for Montreal Cognitive Assessment (MoCA) in prodromal dementia. J Neurol Neurosurg Psychiatry 2017; 88:186-187. [PMID: 27521376 DOI: 10.1136/jnnp-2016-314435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 07/20/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Hanna Lu
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, China.,Department of Psychiatry, Guangzhou Brain Hospital, Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Linda C W Lam
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, China
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48
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Affiliation(s)
- Martin R Turner
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kevin Talbot
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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49
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Moreton FC, Brenner R, Lazarus J, Davenport R. Clinicopathological case: progressive cognitive decline with gait disturbance in a steel worker. Pract Neurol 2016; 17:159-166. [PMID: 27927776 DOI: 10.1136/practneurol-2016-001527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2016] [Indexed: 11/03/2022]
Abstract
A 57-year-old male steel plant worker presented with fatigue and altered liver function tests. Over the next two years, he developed cognitive decline, parkinsonism and seizures. This paper reports the clinicopathological conference at the 37th Edinburgh Advanced Neurology Course 2015 and outlines what we can learn from this case.
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Affiliation(s)
- Fiona C Moreton
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | | | - Jayam Lazarus
- Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, Lincolnshire, UK
| | - Richard Davenport
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
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50
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Soysal P, Isik AT, Stubbs B, Solmi M, Volpe M, Luchini C, D'Onofrio G, Pilotto A, Manzato E, Sergi G, Schofield P, Veronese N. Acetylcholinesterase inhibitors are associated with weight loss in older people with dementia: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2016; 87:1368-1374. [PMID: 27261502 DOI: 10.1136/jnnp-2016-313660] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/10/2016] [Accepted: 05/12/2016] [Indexed: 11/04/2022]
Abstract
We conducted a systematic review and meta-analysis investigating the influence of acetylcholinesterase inhibitors (AChEIs) therapy on nutritional status and weight across observational and interventional studies. Two authors searched major electronic databases from inception until 10/14/2015 for longitudinal, open-label and randomised double-blind placebo controlled (randomised controlled trials (RCTs)) studies of AChEIs in patients with dementia reporting nutritional status outcome data. Out of 3551 initial hits, 25 studies (12 open-label trials, 9 RCTs and 4 longitudinal studies) including 10 792 patients with dementia were meta-analysed. In longitudinal studies (median follow-up 6 months), a significant cumulative incidence of weight loss between baseline and follow-up evaluation was observed (studies=2; 5%; 95% CI 1% to 34%, p<0.0001; I2=95%). These findings were confirmed in open-label trials (6%; 95% CI 4% to 7%, p<0.0001; I2=78%). In 9 RCTs (median follow-up 5 months), those taking AChEIs more frequently experienced weight loss than participants taking placebo (OR=2.18; 95% CI 1.50 to 3.17, p<0.0001; I2=29%). AChEIs therapy contributes to weight loss in patients with dementia, with a 2-fold increased risk observed in the meta-analysis of RCTs. Clinicians should carefully consider the benefit and risk of prescribing AChEIs. Nutritional status should be routinely evaluated in patients with dementia treated with AChEIs.
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Affiliation(s)
- Pinar Soysal
- Faculty of Medicine, Department of Geriatric Medicine, Center for Aging Brain and Dementia, Dokuz Eylul University, Izmir, Turkey
| | - Ahmet Turan Isik
- Faculty of Medicine, Department of Geriatric Medicine, Center for Aging Brain and Dementia, Dokuz Eylul University, Izmir, Turkey
| | - Brendon Stubbs
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Health Service and Population Research Department, Institute of Psychiatry, King's College London, London, UK.,Health, Social Care and Education, Anglia Ruskin University, Chelmsford, UK
| | - Marco Solmi
- Department of Neurosciences, University of Padova, Padova, Italy.,Psychiatry Unit, Monselice, Italy
| | | | - Claudio Luchini
- APSS Trento, Surgical Pathology Unit, Santa Chiara Hospital, Trento, Italy.,Department of Pathology, University of Verona, Verona, Italy
| | - Grazia D'Onofrio
- Geriatric Unit & Laboratory of Gerontology and Geriatrics, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Alberto Pilotto
- Department of Ortho Geriatrics, Rehabilitation and Stabilization, Frailty Area, E.O. Galliera Hospital, NR-HS, Genoa, Italy
| | - Enzo Manzato
- Department of Medicine, Geriatrics Section, University of Padova, Padova, Italy
| | - Giuseppe Sergi
- Department of Medicine, Geriatrics Section, University of Padova, Padova, Italy
| | - Patricia Schofield
- Health, Social Care and Education, Anglia Ruskin University, Chelmsford, UK
| | - Nicola Veronese
- Department of Medicine, Geriatrics Section, University of Padova, Padova, Italy
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