Involvement of the Thalamus, Hippocampus, and Brainstem in Hypsarrhythmia of West Syndrome: Simultaneous Recordings of Electroencephalography and fMRI Study

BACKGROUND AND PURPOSE

West syndrome is a developmental and epileptic encephalopathy characterized by epileptic spasms, neurodevelopmental regression, and a specific EEG pattern called hypsarrhythmia. Our aim was to investigate the brain activities related to hypsarrhythmia at onset and focal epileptiform discharges in the remote period in children with West syndrome using simultaneous electroencephalography and fMRI recordings.

MATERIALS AND METHODS

Fourteen children with West syndrome underwent simultaneous electroencephalography and fMRI at the onset of West syndrome. Statistically significant blood oxygen level-dependent responses related to hypsarrhythmia were analyzed using an event-related design of 4 hemodynamic response functions with peaks at 3, 5, 7, and 9 seconds after the onset of each event. Six of 14 children had focal epileptiform discharges after treatment and underwent simultaneous electroencephalography and fMRI from 12 to 25 months of age.

RESULTS

At onset, positive blood oxygen level-dependent responses were seen in the brainstem (14/14 patients), thalami (13/14), basal ganglia (13/14), and hippocampi (13/14), in addition to multiple cerebral cortices. Group analysis using hemodynamic response functions with peaks at 3, 5, and 7 seconds showed positive blood oxygen level-dependent responses in the brainstem, thalamus, and hippocampus, while positive blood oxygen level-dependent responses in multiple cerebral cortices were seen using hemodynamic response functions with peaks at 5 and 7 seconds. In the remote period, 3 of 6 children had focal epileptiform discharge-related positive blood oxygen level-dependent responses in the thalamus, hippocampus, and brainstem.

CONCLUSIONS

Positive blood oxygen level-dependent responses with hypsarrhythmia appeared in the brainstem, thalamus, and hippocampus on earlier hemodynamic response functions than the cerebral cortices, suggesting the propagation of epileptogenic activities from the deep brain structures to the neocortices. Activation of the hippocampus, thalamus, and brainstem was still seen in half of the patients with focal epileptiform discharges after adrenocorticotropic hormone therapy.

Reconsidering the overdiagnosis of mild cognitive impairment for dementia prevention among adults aged ≥80 years

A diagnosis at the stage of mild cognitive impairment (MCI) is encouraged to promote dementia prevention since intensive intervention during the mild stage is thought to be effective for dementia prevention. Many adults aged ≥80 years hope to prevent dementia; however, several issues should be considered regarding the diagnosis of MCI. First, the diagnosis of MCI is not clear-cut in actual medical practice, with the differentiation of MCI from normal states and mild dementia being blurred. Second, although MCI due to Alzheimer's disease can be differentiated from MCI without pathological changes, interventions specific to MCI due to Alzheimer's disease have not been developed. Third, the diagnosis of MCI can cause self-stigma, leading to psychological effects such as depression and anxiety for both the patients and their families, which can be risk factors for developing dementia for patients. In addition, medical resources are limited and diagnosing MCI is costly in medical human resources. Considering these issues, diagnosing MCI to promote dementia prevention should be viewed from the perspective of the individual patient's interests, especially for those aged ≥80 years. The final decision regarding receiving a diagnosis or not should be the patient's; therefore, it is necessary to increase patients' health literacy, which requires medical professionals to provide them with appropriate evidence-based information. At the same time, it is important to provide psychological support to people who have been diagnosed.

Discrepancies in persons with dementia, family members, and physician perspectives of dementia treatment: a descriptive study

BACKGROUND

This study aims to reconsider diagnostic approaches to dementia where pharmacological approaches are not available to reverse the pathological changes caused by dementia.

METHODS

A questionnaire survey was conducted with 524 physicians specialising in dementia management in Aichi, Japan, with 163 (31.1%) valid responses. The survey gathered information on the perceived merits and demerits of the early diagnosis of dementia and the priorities in treating those with mild cognitive impairment (MCI), mild dementia, and moderate or advanced dementia. In the interview survey, 27 outpatients with mild Alzheimer's disease (76.2 ± 7.6 years old; Mini-Mental State Examination score 23.3 ± 2.7 points; 21 women, six men) and 24 family members (12 spouses, 12 children) were asked about their priorities in treatment.

RESULTS

A total of 61.3% of physicians answered that persons with dementia having more time to accept the diagnosis is a merit of early diagnosis, while 61.3% answered that the possibility of causing anxiety was a demerit. Around 45% of the physicians chose the option 'maintaining cognitive function' as the first priority in cases of MCI and mild dementia, while 39.3% considered it the last priority in moderate or advanced cases. About 22.2% of persons with dementia and 37.5% of their families assigned the highest priority to 'maintaining cognitive function', whereas 37.0% of persons with dementia prioritised 'maintaining quality of life for them and their families'.

CONCLUSIONS

Although it is important to build therapeutic alliances among persons with dementia, their families, and physicians by sharing a common perspective for better treatment of dementia, this study suggested that the three parties do not always share the same vision. Future research is needed to determine how to build therapeutic alliances for better approaches to dementia, especially to ensure that timely diagnosis is beneficial for persons with dementia and their families.

Effect of financial incentives for participation in dementia prevention and support activities: results of a web survey with persons aged 60 and older

BACKGROUND

This study aims to elucidate the impact of financial incentives on the motivation to participate in dementia prevention activities and to provide support to people with dementia.

METHODS

An online survey was completed by 1500 men and women, aged 60 or above, from the general community in Japan. When responding to questions regarding motivation for participating in dementia prevention activities and providing support to people with dementia, respondents were randomly assigned different incentive conditions. Two incentive options were used for dementia prevention activities (no incentives, and a small number of reward points). Three incentive options were used for support activities (no incentives, a small cash reward, or an in-kind time reward that allowed respondents or their family members to use similar services at a later time (time credits)).

RESULTS

Financial incentives decreased motivation for participating in dementia prevention activities, while time credits significantly increased motivation to participate in providing support to people with dementia for going out of their home, when receiving a cash reward was compared with receiving no reward. No significant differences by incentive were found for participating in daily living support for those with dementia or for providing support at a dementia café where people with dementia and their families interact.

CONCLUSIONS

The adverse influence of financial incentives on motivation to participate in dementia prevention suggested that financial incentives may reduce intrinsic motivation for dementia prevention activities. The positive effects of time credits in providing support to people with dementia in going out suggested that time credits might be effective for some support activities for people with dementia. Different incentive measures should be considered to raise awareness of dementia prevention and dementia support activities.

Sally-Anne test and regional cerebral blood flow in Alzheimer's disease dementia

AIM

It was recently reported that theory of mind is disturbed in mild Alzheimer's disease dementia (ADD). Some studies have reported reduced scores of ADD patients on false belief tests, even on first-order false belief tests. However, few studies have pursued the neural substrate of false belief tests in patients with ADD in a real-world setting.

METHODS

Sixty-three patients with ADD from outpatient units took the Sally-Anne test and underwent brain single-photon emission computed tomography. Of these patients, 29 answered the Sally-Anne test correctly (successful group) and 34 incorrectly (unsuccessful group). We compared the regional cerebral blood flow between the successful and unsuccessful groups.

RESULTS

A comparison of the two groups showed a significantly lower uptake in the bilateral posterior cingulate gyrus in the unsuccessful group than in the successful group.

CONCLUSIONS

The posterior cingulate gyrus is known to be particularly activated when individuals remember personal events and infer the mental states of others. We suppose that memory or mentalization in the posterior cingulate gyrus-or both-is essential for patients with ADD to be able to pass the Sally-Anne test.

Effects of attachment to and participation in the community on motivation to participate in dementia prevention and support activities: analysis of Web survey data

AIM

The objective of this study was to elucidate the effects of a sense of attachment to the community (attachment) and participation in community activities (participation) on motivation to participate in dementia prevention and support activities (motivation).

METHODS

We conducted a nationwide Web-based questionnaire survey of 1693 men and women aged ≥20 years. The questionnaire items used in the analysis asked about the following: (i) demographic characteristics (i.e. gender, age, marital status, household income (monitor-registered data), elderly family members, number of years of residency); (ii) attachment; (iii) participation; (iv) self-assessment of dementia knowledge; (v) nursing care experience; (vi) contact with individuals with dementia; (vii) attitudes towards dementia and people with dementia; and (viii) motivation.

RESULTS

Positivity towards dementia and negativity towards dementia were extracted as factors in exploratory factor analysis of attitudes towards dementia and people with dementia. Multiple regression analysis with extracted factors as dependent variables showed that attachment and participation exerted positive effects on attitudes towards dementia (both P < 0.001). The direct effects of attachment and participation on motivation were significant in hierarchical multiple regression analysis (both P < 0.001), and path analysis demonstrated the paths of the effects of attachment and participation on motivation (both P < 0.001). The bias-corrected bootstrap method showed that both attachment and participation exerted direct and indirect (via the mediation of attitudes towards dementia) effects on motivation to participate in the community (all P < 0.001).

CONCLUSION

The results showed that attachment and participation were both determinants of positive attitudes towards dementia and, thus, exerted effects on motivation, both directly and indirectly. These findings suggested that the enhancement of attachment and promotion of participation could lead to the promotion of dementia prevention and support activities in communities and increase dementia awareness.

Social problems in daily life of patients with dementia

AIM

Most patients with dementia frequently encounter various problems in their daily lives. Those troubles embarrass both the patients and their families, and cause problems for society. However, there have been few scientific reports on the difficulties in the daily life of patients with dementia. Therefore, we tried to clarify the frequency and characteristics of troubles experienced by patients with dementia.

METHODS

Seven medical centers treating dementia patients in Okayama Prefecture, Japan, participated in this survey. A total of 737 patients were placed in one of the three groups: a dementia group (n = 478), a mild cognitive impairment group (n = 199) and a control group (n = 60). The frequency of 13 difficulties was scored for each patient.

RESULTS

Among normal participants, no person caused these problems once a year or more frequently. "Massive, recurrent buying" and "acts that risk causing a fire" were reported once a year or more for >10% of mild cognitive impairment patients. "Troubles with wealth management" and "troubles with money management" were the most frequent problems of dementia patients.

CONCLUSIONS

Several problems are already sometimes encountered in patients with mild cognitive impairment. It would be useful to know which social difficulties are often seen in dementia patients in order to protect the safety of the patients. It is always difficult to balance respecting the autonomy of dementia patients and ensuring their safely. Geriatr Gerontol Int 2019; 19: 113-118.

Rehabilitation to live better with dementia

The goal of dementia treatment is to improve the quality of life for both people with dementia and their families. Rehabilitation as a non-pharmacological approach, coordinated with pharmacological treatment, aims to allow patients to live better by slowing the progression, and relieving the behavioral and psychological symptoms of dementia. In dementia, the manifestation of symptoms caused by neurological impairment is modified by various factors; thus, multidimensional assessment and approaches are effective based on the concept of the International Classification of Functioning, which emphasizes the healthy components of every person's functioning. Regarding the process of rehabilitation, every person with dementia should take initiative throughout the course of rehabilitation, and shared decision-making is a fundamental requirement at every phase of intervention. The needs of rehabilitation differ depending on the stage of dementia. In the early stages, cognitive rehabilitation is needed, and interventions are carried out using preserved functions and compensatory strategies. As the disease progresses, capacities of instrumental and then basic activities of daily living deteriorate, and interventions need to be tailor-made and carried out in the context of actual living situations. In the early-to-moderate stages, prevention and management of behavioral and psychological symptoms of dementia are required. In the interventions to alleviate behavioral and psychological symptoms of dementia, it is critical to consider the individual and the meaning behind his/her behaviors from a holistic perspective. Family carers also need support, and education to learn coping strategies can be beneficial for both people with dementia and their carers. Rehabilitation can empower people with dementia and their families to live better with dementia. Geriatr Gerontol Int 2018; 18: 1529-1536.

Letter to the Editor: Preventing Dementia through Community Involvement and Altruistic Behaviors

Population-based studies on dementia prevention have focused on exercise, nutrition, and maintaining social involvement and the effectiveness of these interventions has been determined based on cognitive functions assessed using standardized tests, such as memory function (1, 2). However, the question arises whether all human cognitive functions can be measured with standardized cognitive tests alone. The human brain is assumed to have evolved for cooperation in social settings, and altruistic behaviors and cooperative behaviors have been found mostly in humans. Thus social cognition, which is difficult to be measured with standardized cognitive tests, can be the essence of human cognitive function.

Outcomes of flexor tendon repairs in zone 2 subzones with early active mobilization

We report on the outcomes of flexor tendon repair in zone 2 subzones with early active mobilization in 102 fingers in 88 consecutive patients. There were 28, 53, 15, and six fingers with repairs in zones 2A to 2D, respectively. Rupture of the repair occurred in four fingers, all in zone 2B. Excluding those with repair ruptures, the mean total active motion was 230° (range 143°-286°). Evaluated with Tang's criteria, the outcomes were ranked excellent in 39 fingers, good in 46, fair in ten, poor in three, and failure in four. The outcomes in zone 2C were significantly inferior to those in zones 2B and 2D ( p = 0.02). Our results suggest that the tendon laceration in the area covered by the A2 pulley (zone 2C) is the most difficult area to obtain satisfactory active digital motion and tendon repair in zone 2B is the area where the risk of rupture is highest.

LEVEL OF EVIDENCE

IV.

Clinical results of releasing the entire A2 pulley after flexor tendon repair in zone 2C

We report the results of complete release of the entire A2 pulley after zone 2C flexor tendon repair followed by early postoperative active mobilization in seven fingers and their comparisons with 33 fingers with partial A2 pulley release. In seven fingers, release of the entire A2 pulley was necessary to allow free gliding of the repairs in five fingers and complete release of both the A2 and C1 pulleys was necessary in two. No bowstringing was clinically evident in any finger. Two fingers required tenolysis. Using Tang's criteria, the function of two digits was ranked as excellent, four good and one fair; there was no failure. The functional return in these seven fingers was similar with that in 33 fingers with partial A2 pulley release; in these patients only one finger required tenolysis. Our results support the suggestion that release of the entire A2 pulley together with the adjacent C1 pulley does not clinically affect finger motion or cause tendon bowstringing, provided that the other pulleys are left intact.

LEVEL OF EVIDENCE

IV.

Prevention of cognitive and physical decline by enjoyable walking-habituation program based on brain-activating rehabilitation

AIM

Evaluating effects of an enjoyable walking-habituation program.

METHODS

We carried out a 12-week intervention, consisting of an enjoyable walking-habituation program based on five principles of brain-activating rehabilitation: pleasant atmosphere, interactive communication, social roles, praising each other and errorless support. The program, once a week for 90 min, was carried out in small groups. Participants were 71 community-dwelling people (72.2 ± 4.3) without dementia. Cognitive function was evaluated in five cognitive domains: memory, executive function, word fluency, visuospatial abilities and sustained attention. Additionally, quality of life, depressive state, functional capacity, range of activities, social network and subjective memory complaints were assessed using questionnaires. Motor function was also evaluated. Measurement was carried out before the observation period, after observation and after intervention.

RESULTS

A total of 63 participants were included in the analysis. Daily steps, executive function, subjective memory complaints, functional capacity and 5-m maximum walking time significantly improved during the intervention period (after observation to after intervention) compared with the observation period (before the observation period to after observation). No significant differences were seen in other evaluations. At 6 months after the intervention, 52 of 63 participants (82.5%) continued to walk once a week or more, and all of them were confident about continuing to walk in the future. Furthermore, all participants were satisfied with our walking-habituation program and all replied that they felt delighted.

CONCLUSION

The intervention program, based on the five principles of brain-activating rehabilitation, resulted in improvement of some cognitive and physical functions, as well as a high walking-habituation rate at 6 months' follow up. Geriatr Gerontol Int 2015; ●●: ●●-●●.

Outcomes of release of the entire A4 pulley after flexor tendon repairs in zone 2A followed by early active mobilization

We report the outcomes of repair of the flexor digitorum profundus tendon in zone 2a in 22 fingers. The tendon was repaired with a six-strand repair method and the A4 pulley was completely released. Release of the C2 pulley combined with the A4 pulley was necessary in 12 fingers, nine fingers underwent a complete release of the A3, C2, and A4 pulleys, and one finger underwent a release of the C1, A3, C2, and A4 pulleys. The mean total active motion of the three finger joints was 234° at 5 to 12 months of follow-up. No bowstringing was noted in these fingers. The good and excellent recovery of active digital motion was in 20 (91%) out of 22 fingers according to Strickland's criteria or Tang's criteria. Our results suggest that release of the A3, C2, and A4 pulleys makes the repair surgery easier and does not cause tendon bowstringing.

Magnetoencephalography study of the effect of attention modulation on somatosensory processing in patients with major depressive disorder

AIMS

Although affective and/or attention modulation of somatosensory processing has been well studied, the biological bases of somatic symptoms in patients with major depressive disorder (MDD) have rarely been examined. To elucidate changes in somatosensory processing underlying somatic symptoms in patients with MDD, we conducted a magnetoencephalography study of patients with MDD and healthy controls.

METHODS

After median nerve stimulation, somatosensory evoked fields (SEF) were recorded in 10 patients with MDD and 10 sex-, age-, and height-matched healthy volunteers under somatosensory attending, visually attending, and non-attending conditions. The latencies and magnitudes of N20m and P60m SEF were examined.

RESULTS

In the MDD group, P60m latency was significantly prolonged, irrespective of attention modulation, whereas N20m latency and root mean squares N20m and P60m amplitudes remained unchanged. Prolonged P60m latency negatively correlated with the somatosensory threshold, which was relatively high in the MDD group. Prolonged P60m latency also negatively correlated with a state of anxiety during the examination, but not with depressive symptoms or psychotropic medication.

CONCLUSIONS

These results suggested that patients with MDD experience dysfunction in somatosensory information processing, approximately 60 ms after stimuli, irrespective of attentional conditions.

Prevention of cognitive and physical decline by enjoyable walking-habituation program based on brain-activating rehabilitation

AIM

Evaluating effects of an enjoyable walking-habituation program.

METHODS

We carried out a 12-week intervention, consisting of an enjoyable walking-habituation program based on five principles of brain-activating rehabilitation: pleasant atmosphere, interactive communication, social roles, praising each other and errorless support. The program, once a week for 90 min, was carried out in small groups. Participants were 71 community-dwelling people (72.2 ± 4.3) without dementia. Cognitive function was evaluated in five cognitive domains: memory, executive function, word fluency, visuospatial abilities and sustained attention. Additionally, quality of life, depressive state, functional capacity, range of activities, social network and subjective memory complaints were assessed using questionnaires. Motor function was also evaluated. Measurement was carried out before the observation period, after observation and after intervention.

RESULTS

A total of 63 participants were included in the analysis. Daily steps, executive function, subjective memory complaints, functional capacity and 5-m maximum walking time significantly improved during the intervention period (after observation to after intervention) compared with the observation period (before the observation period to after observation). No significant differences were seen in other evaluations. At 6 months after the intervention, 52 of 63 participants (82.5%) continued to walk once a week or more, and all of them were confident about continuing to walk in the future. Furthermore, all participants were satisfied with our walking-habituation program and all replied that they felt delighted.

CONCLUSION

The intervention program, based on the five principles of brain-activating rehabilitation, resulted in improvement of some cognitive and physical functions, as well as a high walking-habituation rate at 6 months' follow up. Geriatr Gerontol Int 2015; ●●: ●●-●●.

Clinical outcomes of early active mobilization following flexor tendon repair using the six-strand technique: short- and long-term evaluations

We evaluated the factors influencing outcomes of flexor tendon repair in 112 fingers using a six-strand suture with the Yoshizu #1 technique and early postoperative active mobilization in 101 consecutive patients. A total of 32 fingers had injuries in Zone I, 78 in Zone II, and two in Zone III. The mean follow-up period was 6 months; 16 patients (19 fingers) participated in long-term follow-up of 2 to 16 years. The total active motion was 230° SD 29°; it correlated negatively with age. The total active motion was 231° SD 28° after repair of the lacerated flexor digitorum superficialis tendon, and was 205° SD 37° after excision of the flexor digitorum superficialis tendon ends (p = 0.0093). A total of 19 fingers showed no significant increases in total active motion more than 2 years after surgery. The rupture rate was 5.4% in our patients and related to surgeons' level of expertise. Five out of six ruptured tendons were repaired by inexperienced surgeons. Level of Evidence IV.

Early detection of dementia in the community under a community-based integrated care system

Early detection of dementia is recommended in the stages from mild cognitive impairment to early dementia, excluding the asymptomatic stage. The advantages of early detection for patients and their caregivers include early receipt of pharmacological and non-pharmacological therapies, and early access to appropriate agencies and/or support networks. The disadvantages include psychological damage related to anxiety and depression, and risk of stigmatization and/or social exclusion. The possibility of false positive diagnoses is also problematic. For detection of dementia, various screening tests and questionnaires have been developed. However, none of these techniques are sensitive and specific enough to avoid false positives. Thus, these screening tools are recommended for assessment of the severity of functional decline after sufficient information has been gathered to suspect dementia. In terms of social services, early detection might delay institutionalization. However, implementation of early detection would add a heavy burden on social resources, especially human resources. For effective implementation of early diagnosis and management of dementia, measures are required to improve social and human resources, including the following: improvement of the diagnostic abilities of general practitioners, improvement of necessary care and support systems after diagnosis, and organizing volunteers to support local communities. Under a community-based integrated care system, each community will create a "tailored" system that meets the health needs, health status and values of the community. Promoting social participation and community involvement of the residents should be one of the key strategies to address the shortage of human resources.

Factors associated with increased caregivers' burden in several cognitive stages of Alzheimer's disease

AIM

To investigate factors associated with caregiver burden (CB) in persons caring for older adults with various cognitive stages of Alzheimer's disease (AD).

METHODS

Participants were 1127 outpatients and their caregivers. Participants comprised 120 older adults with normal cognition (NC), 126 with amnestic mild cognitive impairment (aMCI) and 881 with AD. AD patients were subclassified into four groups by Mini-Mental State Examination (MMSE) score: AD29-24 (n = 117), AD23-18 (n = 423), AD17-12 (n = 254) and AD11-0 (n = 87). Participants and their caregivers underwent comprehensive geriatric assessment batteries including Zarit Burden Interview (ZBI) Barthel Index, Lawton Index, Dementia Behavior Disturbance Scale (DBD) to evaluate CB, Instrumental and Basic Activity of Daily Living (IADL/BADL), and Behavioral and Psychological Symptoms of Dementia (BPSD). The comorbidity of geriatric syndrome and the living situation of the patient/caregiver were also assessed.

RESULTS

ZBI score was higher in patients with lower MMSE score. Multivariate regression analysis identified that DBD was consistently associated with CB in all patients; symptoms related to memory deficit were related to CB in aMCI; differential IADL, such as inability to use a telephone, use transportation, manage finances, shop, cook and take responsibility for own medication, were related to CB in AD29-24, AD23-18 and AD17-12, and geriatric syndrome including falls and motor disturbance, sleep problems, urinary incontinence, and fatigue was related to CB in AD23-18 and AD17-12.

CONCLUSIONS

Multiple factors including BPSD, impaired life function and geriatric syndrome were cognitive stage-dependently associated with CB. Preventive treatment of BPSD and comorbidity, and effective assistance for IADL deficits could contribute to alleviation of CB.

The impact of subjective memory complaints on quality of life in community-dwelling older adults

PURPOSE

The aim of this study was to evaluate the impact of memory complaints on quality of life (QOL) in elderly community dwellers with or without mild cognitive impairment (MCI).

METHODS

Participants included 120 normal controls (NC) and 37 with MCI aged 65 and over. QOL was measured using the Japanese version of Satisfaction in Daily Life, and memory complaints were measured using a questionnaire consisting of four items. The relevance of QOL was evaluated with psychological factors of personality traits, sense of self-efficacy, depressive mood, self-evaluation of daily functioning, range of social activities (Life-Space Assessment), social network size, and cognitive functions including memory. The predictors of QOL were analyzed by multiple linear regression analysis.

RESULTS

QOL was not significantly different between the NC and MCI groups. In both groups, QOL was positively correlated with self-efficacy, daily functioning, social network size, Life-Space Assessment, and the personality traits of extraversion and agreeableness; QOL was negatively correlated with memory complaints, depressive mood, and the personality trait of neuroticism. In regression analysis, memory complaints were a negative predictor of QOL in the MCI group, but not in the NC group. The partial correlation coefficient between QOL and memory complaints was -0.623 (P < 0.05), after scores of depressive mood and self-efficacy were controlled. Depressive mood was a common negative predictor in both groups. Positive predictors were Life-Space Assessment in the NC group and sense of self-efficacy in the MCI group.

CONCLUSIONS

Memory complaints exerted a negative impact on self-rated QOL in the MCI group, whereas a negative correlation was weak in the NC group. Memory training has been widely practised in individuals with MCI to prevent the development of dementia. However, such approaches inevitably identify their memory deficits and could aggravate their awareness of memory decline. Thus, it is critical to give sufficient consideration not to reduce QOL in the intervention for those with MCI.

Evaluation of Anosognosia in Alzheimer's Disease Using the Symptoms of Early Dementia-11 Questionnaire (SED-11Q)

AIMS

The objective is to propose a brief method to evaluate anosognosia in Alzheimer's disease (AD) using the Symptoms of Early Dementia-11 Questionnaire (SED-11Q), a short informant-based screening questionnaire for identifying dementia.

METHODS

The participants were 107 elderly individuals: 13 with a Clinical Dementia Rating (CDR) of 0.5, 73 with mild AD of CDR 1, and 21 with moderate AD of CDR 2. The patients and caregivers answered the SED-11Q independently, and the degree of discrepancy indicated the severity of anosognosia.

RESULTS

THE SCORES WERE AS FOLLOWS: caregiver scores were 2.46 ± 1.85 (mean ± SD) in CDR 0.5, 6.36 ± 3.02 in CDR 1, and 9.00 ± 1.14 in CDR 2; patient scores were 2.00 ± 1.78, 2.55 ± 2.33, and 1.33 ± 2.46, respectively. Discrepancy was 0.46 ± 1.61, 3.81 ± 3.95, and 7.67 ± 2.87, respectively, and the caregiver assessments were significantly higher than the patient assessments in CDR 1 and CDR 2 (p < 0.001 in both groups). The SED-11Q for anosognosia was validated with the standardized Anosognosia Questionnaire for Dementia (AD-Q). The caregiver scores were moderately correlated with behavioral and psychological symptoms of dementia scores (r = 0.524), and the patient scores were moderately correlated with depression scores (r = 0.561).

CONCLUSION

The SED-11Q serves a dual purpose: caregiver assessment is useful for the screening of dementia, and any discrepancy between the patient and the caregiver assessment is considered as an indication of the severity of anosognosia; this can be informative for caregivers and essential for successful care.

Symptoms of Early Dementia-11 Questionnaire (SED-11Q): A Brief Informant-Operated Screening for Dementia

The aim of this study was to develop a brief informant-based questionnaire, namely the Symptoms of Early Dementia-11 Questionnaire (SED-11Q), for the screening of early dementia. 459 elderly individuals participated, including 39 with mild cognitive impairment in the Clinical Dementia Rating scale (CDR) 0.5, 233 with mild dementia in CDR 1, 106 with moderate dementia in CDR 2, and 81 normal controls in CDR 0. Informants were required to fill out a 13-item questionnaire. Two items were excluded after analyzing sensitivities and specificities. The final version of the SED-11Q assesses memory, daily functioning, social communication, and personality changes. Receiver operator characteristic curves assessed the utility to discriminate between CDR 0 (no dementia) and CDR 1 (mild dementia). The statistically optimal cutoff value of 2/3, which indicated a sensitivity of 0.84 and a specificity of 0.90, can be applied in the clinical setting. In the community setting, a cutoff value of 3/4, which indicated a sensitivity of 0.76 and a specificity of 0.96, is recommended to avoid false positives. The SED-11Q reliably differentiated nondemented from demented individuals when completed by an informant, and thus is practical as a rapid screening tool in general practice, as well as in the community setting, to decide whether to seek further diagnostic confirmation.

Communicative competence in Alzheimer's disease: metaphor and sarcasm comprehension

The purpose of this study was to evaluate the deficits of metaphor and sarcasm comprehension in Alzheimer's disease (AD), as pragmatic interpretation such as metaphor and sarcasm comprehension is required in social communication. A total of 31 young normal controls, 104 aged normal controls (ANC), 42 patients with amnesic mild cognitive impairment (aMCI), and 30 patients with mild AD were evaluated by Metaphoric and Sarcastic Scenario Test, which consists of 5 metaphoric and 5 sarcastic questions with 5 answer choices. Scores were analyzed using the repeated measures analysis of variance (metaphor/sarcasm vs 4 participant groups). Sarcasm comprehension, which requires second-order Theory of Mind (ToM), started to deteriorate in ANC, and metaphor comprehension, which requires first-order ToM, started to deteriorate in aMCI, and both deteriorated as disease progressed. Literal interpretation of pragmatic language is characteristic in patients with mild AD. Such misinterpretation would result in social miscommunication, even if they still retained semantic-lexical competence.

Anosognosia: patients' distress and self-awareness of deficits in Alzheimer's disease

We aimed to study how patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD) suffer from awareness of their deficits. Self-awareness was assessed using the Anosognosia Questionnaire for Dementia in 12 pairs of MCI outpatients and caregivers, 23 with mild AD, and 18 with moderate AD. The discrepancy between patient's and caregiver's evaluation (anosognosia) became greater as AD progressed. The predictors of patients' distress, shown by multiple linear regression analyses, were awareness of decline in intellectual or social functioning; self-awareness of deficits in remembering appointments in MCI; in remembering appointments, writing, mental calculation, and understanding the newspaper in mild AD; and in mental calculation and doing clerical work in moderate AD. Caregivers assumed the predictors of patients' distress differently: awareness of deterioration of memory in MCI and mild AD, and basic activities of daily living in moderate AD. Understanding patients' disability from patients' perspective is required for successful care.

Yamaguchi Facial Expression-Making Task in Alzheimer's Disease: A Novel and Enjoyable Make-a-Face Game

Background

To assess the ability to make emotional facial expressions, we newly developed the Yamaguchi facial expression-making task (Y-FEMT).

Method

We recruited 20 normal controls and 61 outpatients: 10 with amnestic mild cognitive impairment (aMCI), 34 with mild Alzheimer's disease (AD), and 17 with moderate AD. In the Y-FEMT, smile and anger expressions were made by arranging face parts. We examined the relationship between each Y-FEMT score and the Mini-Mental State Examination (MMSE) score or overlapping figure identification test (Fig-test).

Results

The Total score (0–20) was nearly achieved in controls (18.9 ± 1.4) and declined with AD progression (aMCI 17.2 ± 2.4, mild AD 15.7 ± 2.6, moderate AD 12.3 ± 2.7). The Anger score (0–10) was significantly lower than the Smile score (0–10) in mild and moderate AD (p = 0.007 and p = 0.006, respectively). The Structure score (0–6 each) correlated well with both the MMSE score (r = 0.44, p < 0.001) and Fig-test (r = 0.45, p < 0.001), whereas the Expression score (0–4 each) correlated only with the MMSE score (r = 0.33, p = 0.01). The Subjective scores (0–4), evaluated by 10 therapists, highly correlated with the Total score. Additionally, the Y-FEMT promoted laughter and a convivial atmosphere.

Conclusion

The Y-FEMT pleasantly assessed the ability to make emotional facial expressions without special equipment. Furthermore, the Y-FEMT may provide helpful clues for caregivers to achieve good communication with AD patients for better care.

Pleasant physical exercise program for prevention of cognitive decline in community-dwelling elderly with subjective memory complaints

AIM

Japan is one of the most rapidly aging societies in the world. Measures to prevent dementia are urgently required in Japan, although such strategies have not yet been established. This study investigated the effectiveness of a pleasant physical exercise intervention on the prevention of cognitive decline in community-dwelling elderly participants with subjective memory complaints. In this intervention, a pleasant atmosphere was emphasized to enhance the participants' motivation.

METHOD

We administered a 12-week intervention program consisting of pleasant physical exercise. This program for the prevention of cognitive decline was carried out as a service of Maebashi city. The service targeted elderly residents aged 65 years and older who had subjective memory complaints. After a control period of 12 weeks, 42 participants, aged between 65-86 years, received intervention once a week at community centers. Participants carried out group exercise, and were encouraged to perform home exercise and walking during the intervention period. The program was carried out by co-medical professional staff, with the help of senior citizen volunteers.

RESULTS

A total of 30 participants were included in the analysis. There was significant improvement on the Wechsler digit symbol substitution test (P = 0.01).

CONCLUSION

Participants with subjective memory complaints who continued the pleasant physical exercise programs for 12 weeks showed improvement in some aspects of cognitive function. Participation of senior citizen volunteers enabled smooth implementation of the program, and alleviated the burden on the professional staff. The pleasant physical exercise intervention described in the present study could be regarded as a community-led intervention to prevent cognitive decline.

Effects of intervention using a community-based walking program for prevention of mental decline: a randomized controlled trial

OBJECTIVES

To evaluate the efficacy of a municipality-led walking program under the Japanese public Long-Term Care Insurance Act to prevent mental decline.

DESIGN

Randomized controlled trial.

SETTING

The city of Takasaki.

PARTICIPANTS

One hundred fifty community members aged 72.0 ± 4.0 were randomly divided into intervention (n = 75) and control (n = 75) groups.

INTERVENTION

A walking program was conducted once a week for 90 minutes for 3 months. The program encouraged participants to walk on a regular basis and to increase their steps per day gradually. The intervention was conducted in small groups of approximately six, so combined benefits of exercise and social interaction were expected.

MEASUREMENTS

Cognitive function was evaluated focusing on nine tests in five domains: memory, executive function, word fluency, visuospatial abilities, and sustained attention. Quality of life (QOL), depressive state, functional capacity, range of activities, and social network were assessed using questionnaires, and motor function was evaluated.

RESULTS

Significant differences between the intervention and control groups were shown in word fluency related to frontal lobe function (F(1, 128) = 6.833, P = .01), QOL (F(1,128) = 9.751, P = .002), functional capacity including social interaction (F(1,128) = 13.055, P < .001), and motor function (Timed Up and Go Test: F(1,127) = 10.117, P = .002). No significant differences were observed in other cognitive tests.

CONCLUSION

Walking programs may provide benefits in some aspects of cognition, QOL, and functional capacity including social interaction in elderly community members. This study could serve as the basis for implementation of a community-based intervention to prevent mental decline.

A randomized controlled trial of brain-activating rehabilitation for elderly participants with dementia in residential care homes

BACKGROUND/AIMS

We aimed to prove the effectiveness of brain-activating rehabilitation for dementia, which consisted of 5 principles: pleasant atmosphere, communication, praising, social role, and supportive care.

METHODS

The design was a randomized controlled trial that was not blinded. Fifty-four elderly participants with dementia (mean age: 85.2 years) were selected. Intervention based on the 5 principles of brain-activating rehabilitation was conducted for 1 h, twice a week, for 12 weeks (24 sessions). The control group had no treatment. Outcome measures consisted of two observation scales, namely sum of boxes in clinical dementia rating (CDR-SB) and the multidimensional observation scale for elderly subjects (MOSES), and two cognitive tests: the Hasegawa dementia scale revised (HDS-R) and trail making test A.

RESULTS

Repeated measure ANCOVA showed a significant interaction for total score of CDR-SB (F = 7.190, p = 0.015) and MOSES (F = 4.525, p = 0.038). There were no significant changes in the two cognitive test scores.

CONCLUSION

Intervention based on the principles of brain-activating rehabilitation was effective in maintaining and improving daily life functions in elderly participants with dementia in residential care homes.

A figurative proverb test for dementia: rapid detection of disinhibition, excuse and confabulation, causing discommunication

BACKGROUND

Communicative disability is regarded as a prominent symptom of demented patients, and many studies have been devoted to analyze deficits of lexical-semantic operations in demented patients. However, it is often observed that even patients with preserved lexical-semantic skills might fail in interactive social communication. Whereas social interaction requires pragmatic language skills, pragmatic language competencies in demented subjects have not been well understood. We propose here a brief stress-free test to detect pragmatic language deficits, focusing on non-literal understanding of figurative expression. We hypothesized that suppression of the literal interpretation was required for figurative language interpretation.

METHODS

 We examined 69 demented subjects, 13 subjects with mild cognitive impairment and 61 healthy controls aged 65 years or more. The subjects were asked the meaning of a familiar proverb categorized as a figurative expression. The answers were analyzed based on five factors, and scored from 0 to 5. To consider the influence of cognitive inhibition on proverb comprehension, the scores of the Stroop Colour-Word Test were compared concerning correct and incorrect answers for each factor, respectively. Furthermore, the characteristics of answers were considered in the light of excuse and confabulation qualitatively.

RESULTS

The proverb comprehension scores gradually decreased significantly as dementia progressed. The literal interpretation of the proverb, which showed difficulties in figurative language comprehension, was related to disinhibition. The qualitative analysis showed that excuse and confabulation increased as the dementia stage progressed.

CONCLUSIONS

Deficits in cognitive inhibition partly explains the difficulties in interactive social communication in dementia. With qualitative analysis, asking the meaning of a proverb can be a brief test applied in a clinical setting to evaluate the stage of dementia, and to illustrate disinhibition, confabulation and excuse, which might cause discommunication and psychosocial maladjustment in demented patients.

Yamaguchi fox-pigeon imitation test (YFPIT) for dementia in clinical practice

BACKGROUND

 In out-patient clinics, having simple procedures to check for signs of dementia is invaluable. In the present study, we evaluated the imitation of hand gestures to detect visuomotor deficits in dementia in clinical practice.

METHODS

In all, 1219 subjects were enrolled in the present study, including 497 with Alzheimer's disease (AD), 98 with dementia with Lewy bodies (DLB), 71 with other types of dementia diseases, 175 with a Clinical Dementia Rating (CDR) of 0.5, and 378 normal controls. All subjects were aged 65 years or older. Subjects were recruited from 10 clinics and two communities. Visuomotor function was evaluated by the Yamaguchi fox-pigeon imitation test (YFPIT), which consists of a simple one-handed sign for 'fox' and a complex two-handed sign for 'pigeon', a rapid, game-like test with low psychological burden.

RESULTS

The success rate (successful/total) for imitating the 'pigeon' hand gesture was reduced as the severity of the dementia increased: 85.7% in normal controls, 60.6% in CDR 0.5 (mild cognitive impairment), 39.2% in CDR 1 (mild dementia), 21.2% in CDR 2 (moderate dementia), and 5.7% in CDR 3 (severe dementia). The success rate for imitating the 'pigeon' hand gesture was higher in patients with DLB than AD within the CDR 1 group (51.2% vs 35.4%, respectively), but lower for patients with DLB than AD within the CDR 2 group (12.5% vs 24.4%, respectively). The success of imitating the hand gesture for 'fox' was similar for patients with AD and DLB. Of those subjects who failed to imitate the hand gesture for 'pigeon', 49.5% of those with AD showed the palm-palm pattern (both palms facing outward), suggesting deficits of perspective conversion from the first-person to the third-person. Conversely, 52.8% of patients with DLB showed a dorsum-dorsum pattern (both dorsa facing outwards), suggesting deterioration of visual attention and recognition.

CONCLUSION

In conclusion, the YFPIT is a useful test to detect visuomotor deficits in dementia that can differentiate between AD and DLB.

Overview of non-pharmacological intervention for dementia and principles of brain-activating rehabilitation

Non-pharmacological interventions for dementia are likely to have an important role in delaying disease progression and functional decline. Research into non-pharmacological interventions has focused on the differentiation of each approach and a comparison of their effects. However, Cochrane Reviews on non-pharmacological interventions have noted the paucity of evidence regarding the effects of these interventions. The essence of non-pharmacological intervention is dependent of the patients, families, and therapists involved, with each situation inevitably being different. To obtain good results with non-pharmacological therapy, the core is not 'what' approach is taken but 'how' the therapists communicate with their patients. Here, we propose a new type of rehabilitation for dementia, namely brain-activating rehabilitation, that consists of five principles: (i) enjoyable and comfortable activities in an accepting atmosphere; (ii) activities associated with empathetic two-way communication between the therapist and patient, as well as between patients; (iii) therapists should praise patients to enhance motivation; (iv) therapists should try to offer each patient some social role that takes advantage of his/her remaining abilities; and (v) the activities should be based on errorless learning to ensure a pleasant atmosphere and to maintain a patient's dignity. The behavioral and cognitive status is not necessarily a reflection of pathological lesions in the brain; there is cognitive reserve for improvement. The aim of brain-activating rehabilitation is to enhance patients' motivation and maximize the use of their remaining function, recruiting a compensatory network, and preventing the disuse of brain function. The primary expected effect is that patients recover a desire for life, as well as their self-respect. Enhanced motivation can lead to improvements in cognitive function. Amelioration of the behavioral and psychological symptoms of dementia and improvements in activities of daily living can also be expected due to the renewed positive attitude towards life. In addition, improvements in the quality of life for both patients and caregivers is an expected outcome. To establish evidence for non-pharmacological interventions, research protocols and outcome measures should be standardized to facilitate comparison among studies, as well as meta-analysis.