Brain Donation by Proxy: Are There Predictors in Neurodegenerative Dementia?

OBJECTIVES

To describe the frequency and predictors of brain donation by relatives in patients with neurodegenerative dementia.

DESIGN

Database review and quantitative analysis.

SETTING

The Alzheimer Center Reina Sofia Foundation (ACRSF), a center devoted to the care and research of patients with neurodegenerative dementia.

PARTICIPANTS

Patients with signed consent for participation in the ACRSF research program.

MEASUREMENTS

A set of 38 demographic, clinical, and social variables related to patient and closest relative, which were collected by the ACRSF multidisciplinary team upon patient admission.

RESULTS

Admission data were available for 198 patients who entered the ACRSF research program; 85 of them (42.9%) died during follow-up. Mean age (SD) at admission was 82.3 (6.8) years and 80.8% of the patients were female. Family link between patient and closest relative was spouse or partner (12.0%), son or daughter (74.9%), or other link (13.1%). Brain was obtained from 56 patients (65.9%). Consent by legal representative and patient's depressive symptoms were more frequent in the donors (p<0.05, corrected) and trend was observed for more aberrant motor symptoms in the donors (p<0.05, uncorrected).

CONCLUSION

A high rate of brain donation was achieved, probably due to the unique characteristics of the ACRSF and consent for research policy. Wish of alleviating suffering, as well as general interest in dementia research, possibly exerted an influence in brain donation. More research is needed to ascertain the values, motivations, and circumstances that may lead to brain donation by proxy in neurodegenerative dementia.

Unexplained pain complaints and depression in older people in primary care

OBJECTIVE

Chronic pain and depression are frequent conditions in primary care patients. Depression is frequently overlooked in the presence of pain of uncertain origin. The aim is to measure the prevalence and clinical correlates of unrecognized comorbid mood disorders and chronic pain of uncertain origin in older primary care patients, and to elucidate the differences with younger adults with the same conditions.

DESIGN

Cross-sectional study.

SETTING

Primary care centres in Spain.

PARTICIPANTS

Patients (n= 2720) with persistent pain of uncertain origin.

MEASUREMENTS

Pain characteristics, sites and intensity (Visual Analogical Scales), depression (PRIME-MD interview), clinical characteristics and health services use.

RESULTS

We observed a similarly high (80.5%) prevalence of undiagnosed mood disorders (especially major depressive disorders) among older and younger adult patients with comorbid chronic pain complaints of uncertain origin. Older patients suffered pain that was more intense, longer lasting and located in a higher number of different areas, when compared to younger patients. Pain intensity was a factor associated with suffering from mood disorders among patients above 65 years, whilst the number of pain sites was a more important factor among younger patients.

CONCLUSIONS

Depression is highly associated with pain of uncertain origin in older patients with differences in pain characteristics when compared to younger patients. The robust comorbid relationship between both conditions should alert clinicians to specifically look for depression in the presence of poorly explained painful symptoms.

A new apathy scale for institutionalized dementia patients: validation of the APADEM-NH scale short-version

Aims

To describe validation process of the new apathy scale for institutionalized dementia patients (APADEM-NH).

Methods

100 elderly, institutionalized patients with diagnosis of probable Alzheimer Disease (AD) (57%), possible AD (13%), AD with cerebral vascular disease (CVD) (17%), Lewy Bodies Dementia (11%) and Parkinson associated to dementia (PDD) (2%). All stages of the disease severity according to the Global Deterioration Scale (GDS) and Clinical Dementia Rating (CDR) were assessed. The Apathy Inventory (AI), Neuropsychiatric Inventory (NPI), Cornell scale for depression, and the tested scale were applied. Re-test and inter-rater reliability was carried out in 50 patients. The feasibility and acceptability, reliability, validity, and measurement precision were analyzed.

Results

APADEM-NH final version consists of 26 items and 3 dimensions: Deficit of Thinking and Self-Generated behaviors (DT): 13 items, Emotional Blunting (EB): 7 items, and Cognitive Inertia (CI): 6 items. Mean application time was 9.56 minutes and 74% of applications were fully computable. All subscales showed floor and ceiling effect lower than 15%. Internal consistency was excellent for each dimension (Cronbach’s α DT = 0.88, α EB = 0.83, α CI= 0.88);Test-retest reliability for the items was kW=0,48-0,92; Inter-rater reliability reached kW values 0.84-1.00; The APADEM-NH total score showed a low/moderate correlation with apathy scales (Spearman ρ, AI =0.33; NPI-Apathy= 0,31), no correlation with depression scales (NPI-Dementia = -0.003; Cornell= 0,10), and high internal validity (ρ =0.69 0.80).

Conclusions

APADEM-NH is a brief, psychometrically acceptable, and valid scale to assess apathy in patients from mild to severe dementia and discerning between apathy and depression.

Diagnostic criteria for apathy in clinical practice

BACKGROUND

Apathy is an important and distressing behavioural symptom in Alzheimer's disease and in various neuropsychiatric disorders. Recently, diagnostic criteria for apathy have been proposed.

OBJECTIVES

In groups of patients suffering from different neuropsychiatric diseases, (i) to estimate the prevalence of patients meeting the proposed diagnostic criteria; (ii) to estimate the concurrent validity of the criteria with the neuropsychiatric inventory (NPI) apathy item; (iii) to identify the most frequently met criteria or sub-criteria in each specific neuropsychiatric disease and (iv) to estimate the inter-observer reliability of the diagnostic criteria for apathy.

METHODS

This cross-sectional, multicentric, observational study was performed on 306 patients. Each of the participating centres had to check the presence of apathy according to the diagnostic criteria for apathy in consecutive patients belonging to the following diagnoses list: Alzheimer disease (AD), mixed dementia, mild cognitive impairment (MCI), Parkinson's disease (PD), Schizophrenia (DSM-IV) and major depressive episode. In addition to the clinical interview, the assessment included the Mini Mental Score Examination (MMSE) and the NPI. At the end of the visit, clinicians were required to check the diagnostic criteria for apathy.

RESULTS

Using the diagnostic criteria for apathy, the frequency of apathy was of 53% in the whole population, 55% in AD, 70% in mixed dementia, 43% in MCI, 27% in PD, 53% in schizophrenia and 94% in major depressive episode. In AD, mixed dementia, MCI and PD, the NPI apathy score was significantly higher for patient fulfilling the apathy criteria. Goal-directed cognitive activity (criteria B2-Cognition) was the most frequently observed domain followed by goal-directed behaviour (criteria B1-Behaviour) and emotion (criteria B3), respectively. Inter-rater reliability was high for the overall diagnostic (κ coefficient = 0.93; p = 0.0001) and for each criteria.

CONCLUSION

This study is the first one to test the diagnostic criteria for apathy in clinical practice. Results make the diagnostic criteria useful for clinical practice and research.

Consensus of the SEPG on depression in the elderly

BACKGROUND

The limitation of clinical-epidemiological know-how and evidence regarding therapeutic efficiency in depression among the elderly and extremely elderly patients has given rise to an excessive variety of practices in clinical care of these patients in the Spanish health system. The Spanish Society of Psychogeriatrics (SEPG) has raised the question of the need to unify criteria through a structured approach based on professional consensus.

OBJECTIVES

To develop an expert consensus of clinical recommendations to improve the clinical treatment of depression in elderly patients in Spain, sponsored by the Spanish Society of Psychogeriatrics (SEPG).

METHODS

Modified Delphi Consensus, in two rounds. The study was conducted in four phases: 1) constitution of a Scientific Committee, project promoter and responsible for bibliographic review and formulation of recommendations for discussion 2) constitution of a multicenter Panel of Experts with representatives from this specialist field 3) postal survey comprised of two rounds, with interim processing of opinions and a report for the experts and 4) discussion of results during an on-site meeting of the Scientific Committee.

RESULTS

The survey evaluation was completed by 61 experts consulted, in two rounds. In the first round, consensus was reached in 39 of the 54 questions analyzed. Following interaction by the panel, this consensus was increased to a total of 46 survey items (85% of the proposed contents). It was impossible to obtain a sufficiently unanimous consensus on the remaining 8 questions, either due to differences of opinion among the professionals or a lack of established criterion in most of the experts.

CONCLUSIONS

A full list of criteria and clinical recommendations for the purpose of rationalizing the treatment of depression in elderly patients and reducing excessive variability in clinical practice is presented. The recommendations are qualified in accordance with the degree of consensus of the professionals endorsing them and can be considered valid until new scientific information becomes available that justifies their review.

[Effectiveness of venlafaxine extended release and conventional antidepressants in elderly patients with depressive disorder]

OBJECTIVES

To determine and compare effectiveness, tolerability and safety of venlafaxine extended release (VXR) and other conventional antidepressants, mainly selective serotonin reuptake inhibitors (SSRIs), for the treatment of elderly patients diagnosed of depressive disorder in an out-patient psychiatry setting.

METHODS

Multicenter, naturalistic, randomized, openlabel study performed in elderly patients with depressive disorder (according to DSM-IV). Patients were randomized to 6 months of treatment with VXR or another conventional antidepressant (CA). Effectiveness was assessed using the Montgomery- AAsberg Depression Rating Scale (MADRS) and the Hamilton Anxiety Scale (HAM-A). Response was considered as a > or = 50 % decrease and remission as a < 9 score in the MADRS.

RESULTS

Sample of 120 patients older than 60 years; 68 received VXR and 52 CA (SSRI: 94.1 %). Most frequently used SSRI were citalopram (40.8 %), paroxetine (24.5 %) and sertraline (20.4 %). After 6 months of treatment, VXR achieved a higher response (75 %, VXR; 50 %, CA; p = 0.048) and remission (50 %, VXR; 28.9 %, CA; p = 0.048) and a higher decrease in the HAM-A score (-14.77, VXR; -10.84, CA). There were no significant differences in compliance rates (67.6, VXR; 71.1 %, CA) and adverse reactions (14.7 %, VXR; 13.46 %, CA) between both treatment groups. Blood pressure and heart rate remained within normal limits in both treatment groups.

CONCLUSIONS

In this study, venlafaxine extended release shows higher effectiveness than other conventional antidepressants, mainly SSRIs, in the treatment of depressive elderly patients in the out-patient psychiatry setting.

Practical psychological management of old age psychosis

Late-onset forms of psychosis have been the object of increasing interest in recent years. Despite the fact that there are still many obscure areas, significant advances in the pathophysiology, delimitation of risk factors, clinical presentation, neuropsychology and the pharmacological treatment have been made. Nevertheless, the psychological aspects of both aetiology and treatment of these late forms of psychosis have received much less attention than the rest. In contrast with that, the clinician is confronted with the need to manage patients that are reluctant to take medications and in which the outcome of pharmacological treatments is not always optimal. The elderly psychotic patient should not be excluded from the possibility of receiving any kind of psychological help. He may benefit from adaptations of different psychotherapeutic measures that can include the more classical techniques as psychodynamic oriented and behavioural-cognitive therapies or the newer forms of treatment specially designed for the aged, as reminiscence or psychomotor therapy. In any case, to obtain any result the patient needs to be managed in a way that goes well further the prescription of a neuroleptic drug. In this paper we review some of the most important psychological cues for the understanding of the elderly psychotic patient. Furthermore, we divide the therapeutic relationship over the time in three parts: The initial contact, the central phase and the termination. We offer some keys for the practical management of the patient in each of these phases, with special attention to the adherence to treatment and early identification of treatment-emergent complications like depressive symptoms or hypochondriac concerns.