Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology

OBJECTIVE: The goal of this project was to determine whether screening different groups of elderly individuals in a general or specialty practice would be beneficial in detecting dementia. BACKGROUND: Epidemiologic studies of aging and dementia have demonstrated that the use of research criteria for the classification of dementia has yielded three groups of subjects: those who are demented, those who are not demented, and a third group of individuals who cannot be classified as normal or demented but who are cognitively (usually memory) impaired. METHODS: The authors conducted computerized literature searches and generated a set of abstracts based on text and index words selected to reflect the key issues to be addressed. Articles were abstracted to determine whether there were sufficient data to recommend the screening of asymptomatic individuals. Other research studies were evaluated to determine whether there was value in identifying individuals who were memory-impaired beyond what one would expect for age but who were not demented. Finally, screening instruments and evaluation techniques for the identification of cognitive impairment were reviewed. RESULTS: There were insufficient data to make any recommendations regarding cognitive screening of asymptomatic individuals. Persons with memory impairment who were not demented were characterized in the literature as having mild cognitive impairment. These subjects were at increased risk for developing dementia or AD when compared with similarly aged individuals in the general population. RECOMMENDATIONS: There were sufficient data to recommend the evaluation and clinical monitoring of persons with mild cognitive impairment due to their increased risk for developing dementia (Guideline). Screening instruments, e.g., Mini-Mental State Examination, were found to be useful to the clinician for assessing the degree of cognitive impairment (Guideline), as were neuropsychologic batteries (Guideline), brief focused cognitive instruments (Option), and certain structured informant interviews (Option). Increasing attention is being paid to persons with mild cognitive impairment for whom treatment options are being evaluated that may alter the rate of progression to dementia.     

The closure of a major psychiatric hospital: can psychiatric patients in long-term care be integrated into existing nursing homes?

Nursing homes are important alternatives to large hospitals when psychiatrically ill patients are relocated in the community, but their suitability for this type of patient is being questioned. This study compared patients in two traditional Swedish nursing homes (n = 66) and patients in long-term care at a large psychiatric hospital (n = 106). The results showed that both types of institutions housed patients with organic dementia and psychiatric symptoms. The hospitalized demented patients, however, displayed significantly more cognitive impairment, more confusion, and more behavioral disturbances than the nursing home patients. Significant differences were also found between the nursing home patients and hospitalized psychiatrically ill patients without dementia. The latter were younger, had better activities of daily living capacity, but displayed more psychiatric symptoms and behavioral disturbances than the nursing home patients. We concluded that all the patients in long-term psychiatric care will require sheltered accommodation. The demented patients could possibly be integrated into nursing homes, but successful integration would require special arrangements. Psychogeriatric units with staff qualified to care for patients with severe behavioral disturbances would be preferable. It would not be possible to meet the psychiatrically ill patients' special need of care in existing nursing homes. Alternative living arrangements, with care given by staff trained in psychiatry, are recommended.     

THE MICROSTRUCTURE OF EATING IN PEOPLE WITH DEMENTIA WHO ARE HYPERPHAGIC

Objectives. To describe (a) the nature of eating abnormalities and (b) mechanisms of hunger and satiation in hyperphagic subjects with dementia. Design. Case-control study. Three groups of subjects were compared: people with dementia, reported by their carers to be hyperphagic and who overate under experimental conditions; people with dementia who ate normally; normal elderly. Subjects were individually matched across groups. Setting. Subjects with dementia: living either in the community or in long-stay, psychogeriatric wards; the normal elderly controls lived at home. All lived in the UK. Participants. Participants with dementia fulfilled criteria for Alzheimer's disease. Hyperphagic group (n=18): aged 54–91, MMSE scores 0–20. Normal elderly controls (n=14) were individually matched for age and sex. Non-hyperphagic demented controls (n=14) were also matched for cognitive impairment. Measures. Two standardised test meals were given: a single food meal and a mixed food meal. Eating microstructure (latency period before eating; loading rate; chewing rate; rate of energy consumption and behaviour patterns during meal), were measured from videorecordings. Present Behavioural Examination was used to assess eating behaviour and MMSE to test cognitive impairment. Results. The hyperphagic group started to eat much more rapidly than non-hyperphagic demented controls, (W=59.0;p=0.006) and had a significantly higher initial eating rate (t=2.28,p<0.0005). Unlike the normal elderly, neither group with dementia showed a significant deceleration during the meal. Conclusions. People with dementia have impaired satiation mechanisms. Hyperphagic subjects with dementia have more marked impairment of satiation and increased hunger compared with non-hyperphagic demented subjects.     

Caregiving burden and out-of-home mobility of cognitively impaired care-recipients based on GPS tracking

ABSTRACT Background: Out-of-home mobility refers to the realization of trips outside the home, by foot or by other means of transportation. Although out-of-home mobility is important for the well-being of older people with cognitive impairment, its importance for their caregivers is not clear. This study aims to clarify the relationship between caregiving burden and out-of-home mobility of care-recipients using Global Positioning Systems (GPS) technology. Methods: Seventy-six dyads (care-recipients and caregivers) were recruited from a psychogeriatric center, where they underwent cognitive assessment, followed by psychosocial interviews at home. Care-recipients received GPS tracking kits to carry for a period of four weeks, whenever they left home. Mobility data and diagnostic and psychosocial data were examined in relation to caregiver burden. Results: The strongest predictors of burden were care-recipients' lower cognitive status and more time spent walking out-of-home. An interaction was found between cognitive status and time spent walking in relation to caregiver burden. The relationship between walking and burden was stronger among caregivers of care-recipients with dementia than caregivers of care-recipients with no cognitive impairment or mild cognitive impairment. Care-recipients' behavioral and emotional states were also positively related to caregiver burden. Conclusions: The findings stress the importance of maintaining older persons' out-of-home mobility during cognitive decline.     

Prospective analysis of risk factors for nursing home placement of dementia patients.

OBJECTIVE: To examine risk factors for nursing home placement in a community-based dementia cohort. METHODS: Cognitively normal participants and cognitively impaired patients from a large AD Patient Registry were followed from diagnosis to placement, death, or last follow-up. This included over 3,600 person-years of surveillance. The normal group included 473 participants who did not, at any point, meet Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised (DSM-III-R) criteria for dementia. The patient group included 512 patients who met DSM-III-R criteria for dementia or criteria for mild cognitive impairment at diagnosis. Demographic, medical, social, cognitive, behavioral, and functional predictors of time to placement were examined using Cox modeling. RESULTS: In the normal group, only 21 people (4%) required nursing home placement. With subjects, enrollment year, age at initial evaluation, being widowed, and living in a retirement community were associated with time to placement in separate univariate analyses. Of 512 cognitively impaired patients, 203 (39.6%) were placed in nursing homes. Median time from diagnosis to placement was 5.3 years. Within the patient sample, four predictors were determined to be associated with time to nursing home placement. These included gender, enrollment year, functional status, and cognitive score. Interactions were present for functional status with cognitive score and enrollment year. CONCLUSION: In patients with dementia who are within 5 years of diagnosis, placement rates of approximately 10% per year can be expected. Disease severity indices including degree of cognitive and functional impairment are primary risk factors for placement.     

The comparison of burden between caregiving spouses of depressive and demented patients

BACKGROUND: The opportunities for a depressive or demented elderly patient to live at home are dependent on the availability of support. If the spouse is alive, her or his resources to care for the patient are an essential option. In this study we compared the burden of the spouses of depressive and demented elderly patients admitted to the University Psychogeriatric Clinic. METHODS: The Zarit Burden Interview was used when comparing the burden between the groups. Psychological distress was screened by the 12-item General Health Questionnaire. The care and support given by the spouse was assessed by Involvement Evaluation Questionnaire. The spouse's stress related to the health state of the patient was evaluated by the Pearlin Caregiving Stress Inventory. Twenty-two spouses living with a depressive patient and 43 with a demented patient were included in the study. RESULTS: The spouses of demented patients as a group were psychologically more stressed than the spouses of depressive patients. However, when demented patients were divided into two groups, in those admitted mainly for noncognitive symptoms related to dementia and in those admitted for memory assessment and diagnostic purposes, the burden of the spouses in the former group was higher than that of the group of depressive patients' spouses. No difference was found between the latter group of demented patient spouses and depressive patients' spouses. Both the patients and the spouses in the demented group were older than those in the depressive group. However, no correlation was found between stress of the spouse and her or his own age or the age of the patient either within the depressive or within the demented group. As expected, the function level of demented patients was lower than that of depressive patients. A correlation was found within both groups between low functional capacity of the patient and the stress of the spouse. In both groups the spouses who felt their own mental health to be poor were more likely to have high levels of burden. CONCLUSIONS: Among the general psychogeriatric patient groups, the caregiving spouses of demented patients with noncognitive psychiatric symptoms are the most burdened group. However, spouses of depressive patients are as much burdened as those of demented patients with mild to moderate memory impairment. More support is needed for every spouse group caring for psychogeriatric patients.     

Effect of Meeting Centres Support Program on feelings of competence of family carers and delay of institutionalization of people with dementia

The study tested the hypotheses that integrated support, in which patients and carers are both supported by one professional staff member, will be more effective in reducing the feelings of (over)burden of carers and in positively influencing some potential determinants of experienced burden than non-integrated support, such as psychogeriatric day-care. A quasi-experimental pre-test/post-test control group design was applied with matched groups and measurements at baseline and after seven months. Fifty-five of the eighty dyads (31% dropped out) of persons with mild-to-moderate dementia and their carers who presented for four community meeting centres and three day-care centres in nursing homes over an 18 month period, were included in the study. The carers in the Meeting Centres Support (MCS) Program participated in an integrated family support program together with the persons with dementia, while the carers in the control group only received respite through psychogeriatric day-care. Standardized questionnaires were applied to measure some indicators of burden experienced by the carers (feelings of stress, life dissatisfaction, psychological and psychosomatic complaints), as well as some potential determinants of experienced burden (feeling of competence, coping strategies, experienced support and loneliness). Furthermore, as an indicator of feelings of (over)burden of the carer, the time between start of participation in one of the programs and institutionalization in a nursing home was calculated. After seven months the carers in the MCS group (n = 36), compared to the carers in regular psychogeriatric day-care (n = 19), showed a moderate positive effect on the feeling of competence (effect size 0.45). No effect was found on feelings of stress, dissatisfaction or psychological and psychosomatic complaints. However, as compared to the control group in regular day-care, the persons with dementia in the MCS Program participated for a longer period of time before they were placed in a nursing home. The MCS Program proved more effective than psychogeriatric day-care in influencing the feeling of competence of the carers, and seems to lead to an increased delay of nursing home placement of the person with dementia, as compared to regular day-care. Because of the small sample and limited power of the study, and the possible influence of the selection of carers on the study outcome, further research into the value of meeting centres for carers of people with dementia is recommended.     

The naming disorder of dementia

Naming impairment is a common feature of the language disorder of dementia, yet agreement has not been reached on its mechanisms. In this study, the confrontation naming performance of twelve demented subjects was compared to that of age-matched controls. Naming deficits were studied in relation to overall language and cognitive dysfunction and analysed to assess the importance of both perceptual and linguistic factors. Naming dysfunction occurred even in mild dementia, in patients whose overall language function remained normal, and worsened in proportion to the degree both of language deficit and overall cognitive dysfunction. Perceptual difficulty and word frequency, but not word length, were important determinants of naming performance in demented patients.     

The effect of integrated emotion-oriented care versus usual care on elderly persons with dementia in the nursing home and on nursing assistants: a randomized clinical trial

OBJECTIVES: To examine the effect of integrated emotion-oriented care on nursing home residents with dementia and nursing assistants. DESIGN: A multi-site randomized clinical trial with matched groups, and measurements at baseline and after seven months. SETTING: Sixteen psychogeriatric wards in fourteen nursing homes in the Netherlands. PARTICIPANTS: One hundred and forty-six elderly residents with the diagnosis dementia of the Alzheimer (DAT) type, mixed DAT and vascular dementia, and dementia syndrome (NAO) and 99 nursing assistants. INTERVENTIONS: Integrated emotion-oriented care and usual care. MESUREMENTS: Demented elderly: Behaviour and mood related to adaptation to the illness and the institutionalization. Nursing assistants: General health as measured by feelings of stress, stress reactions, feeling of competence and illness. RESULTS: Positive effects in favour of the integrated emotion-oriented care were found in mild to moderately demented residents on two adaptive tasks: maintaining an emotional balance (less anxiety) and preserving a positive self-image (less dissatisfaction). In the trained group of nursing assistants fewer stress reactions were found only in those who perceived improvement in their emotion-oriented care skills after training. CONCLUSION: Emotion-oriented care is more effective with regard to the emotional adaptation in nursing homes of persons with a mild to moderate dementia. For the severely demented elderly we did not find this surplus value. This outcome is of clinical importance for elderly persons with dementia who are cared for in nursing homes. With respect to the nursing assistants it is concluded that emotion-oriented care has a positive influence on stress reactions in some of them.     

Improvement of agitation and anxiety in dementia patients after psychoeducative training of their caregivers

It has been convincingly demonstrated that in dementia psycho-educative training of caregivers positively impacts on motivation for care and satisfaction of the caregivers. It has, however, been neglected to examine the effect of psycho-educative training on the behavioural and psychological symptoms of dementia sufferers. In a three-month, expert-based and conceptualized group intervention with caregiving relatives of demented patients we investigated, whether functional impairment and behavioural and psychological symptoms may improve, which of a set of independent variables may predict improvement, and how the group intervention will be appreciated by the caregivers. The group intervention yielded a significant improvement of memory-related functions in daily living and a significant decrease of agitation and anxiety of the demented patients. The presence of an additional somatic disease predicted worse outcome of the intervention with respect to the impairment of memory-related functions in daily living and of agitation. Anonymous inquiry of the caregivers with respect to their judgement of the intervention revealed high acceptance and appreciation. This study demonstrated that a psycho-educative group intervention with caregiving relatives of dementia sufferers is helpful for both the caregivers and the demented patient. This evidence of a positive mediate effect of the group intervention on the functional and behavioural impairment of the demented patients underscores the importance of nonpharmacological strategies in the treatment plan of dementia.     

Brain structure and cognition in a community sample of elderly Latinos

BACKGROUND: Previous studies have found that hippocampal atrophy and white matter hyperintensities (WMH) on MRI are linked to cognitive impairment and dementia. The authors measured these variables in a population-based cohort of older Mexican Americans with a wide spectrum of cognitive ability, ranging from normal cognition to dementia. OBJECTIVE: To investigate whether these structural brain changes were seen in individuals prior to the development of dementia and how these changes were related to the presence of dementia. METHODS: A sample of 122 subjects was selected from the Sacramento Area Latino Study on Aging, and subjects were categorized into four groups of increasing levels of cognitive impairment: normal, memory impaired (MI), cognitively impaired but not demented (CIND), and demented. Hippocampal volume was quantified using a region of interest approach. WMH was rated on a semiquantitative scale as the percent of total volume of white matter. RESULTS: Hippocampal volume was significantly reduced in CIND and demented individuals, and WMH were significantly increased in demented subjects. MI subjects did not have any significant changes in hippocampal volume or WMH. The risk for developing dementia was significantly and comparably increased in subjects with either hippocampal atrophy or high WMH. However, the risk for dementia increased dramatically in subjects with both hippocampal atrophy and a high degree of WMH. CONCLUSION: Reductions in hippocampal volume may be present before dementia but not until cognitive impairment is relatively severe. Because there is a synergistic effect between high WMH and hippocampal atrophy, interactions between vascular and degenerative processes may be important determinants of dementia.     

The domus philosophy: A comparative evaluation of a new approach to residential care for the demented elderly

This study reports a cross-sectional comparison between three continuing care facilities for severely disturbed elderly demented people: two mental hospital psychogeriatric wards and a unit run according to the domus philosophy of care. The domus was characterized by greater expectations for residents' functioning, policy choice, resident control and availability of social and recreational activities. The level of staffing was higher on the domus than on the two wards. The residents on the three settings were broadly comparable with regard to age, diagnosis, length of stay, objectively assessed cognitive impairment and depression, but the domus residents were rated by the staff as less disabled in self-care tasks, orientation and communication. Direct non-participant observation using the Short Observation Method demonstrated significantly higher levels of activities and staff-resident interaction on the domus compared to the hospital wards. There were no differences between the settings with regard to staff absenteeism, job turnover or psychological impairment, but the domus staff expressed higher levels of job satisfaction. These findings are discussed in the context of the limitations of study design and method.     

Characteristics and outcomes of dementia residents in an assisted living facility

BACKGROUND: Assisted living (AL) is the fastest growing segment of residential long-term care in the US. At least half of the estimated 1 million AL residents have dementia or cognitive impairment, with many AL facilities offering specialized dementia services. Little research has been done on the demographics, outcomes, or clinical variables of this population.METHODS: Participants were a cohort of 144 residents admitted to the AL unit of Copper Ridge, a specialized dementia-care facility. Comparison samples included 737 patients with dementia residing in other locations (home, nursing home, and other assisted living facilities). Selected measures of cognition, behavior, medical health, and function were taken at admission to AL and at 6-month intervals.RESULTS: When compared with residents of the dementia-specialized AL facility, dementia patients at home were younger, less cognitively impaired, and less likely to exhibit wandering, delusions, or aggression. Residents of a dementia-specialized nursing home had more cognitive impairment, greater medical comorbidity, and were more dependent on caregivers. The 2-year mortality rate in the dementia-specialized AL was 23%, significantly lower than rates reported for nursing homes. Primarily due to increasing care needs, most residents in the specialized AL relocated to a nursing home after a median stay of 10.9 months. Depression, falling, and wandering were significant predictors of the transition.CONCLUSION: Dementia-specialized AL facilities occupy a unique position in the long-term care continuum that is distinct from home-care and nursing home facilities. This research is the first step toward understanding the significant dementia population residing in assisted living.     

Rates of progression in mild cognitive impairment and early Alzheimer's disease

OBJECTIVE: To compare rates of progression in the very mildest stages of AD, including the stage currently identified as mild cognitive impairment (MCI), and to identify predictors of those rates. METHODS: Demented (n = 289) and nondemented (n = 230) individuals enrolled in longitudinal studies at an Alzheimer Disease Research Center received annual clinical and psychometric examinations for up to 20 years. In order of increasing dementia severity, demented individuals were diagnosed with incipient, very mild, or mild dementia; the incipient stage is equivalent to MCI. Outcome measures included death, nursing home placement, and psychometric scores. RESULTS: Rate of progression increased with dementia severity as staged by the Clinical Dementia Rating at entry into the study. With respect to the dichotomous outcomes, the increase with dementia severity was more dramatic for the endpoint of nursing home entry than it was for the endpoint of death. Increased rates of cognitive decline with increased dementia severity were also obtained for psychometric scores. There was limited evidence of other predictors of progression. CONCLUSIONS: The lack of effective predictors of the rate of dementia progression extends to the very earliest stages of the disease, including what is often called MCI. A new approach to the identification of correlates of rates of progression is needed.     

The Cambridge Cognitive Examination (CAMCOG): validation of the Hebrew version in elderly demented patients

BACKGROUND AND PURPOSE: The CAMCOG is the second most popular cognitive testing instrument in use by Israeli clinicians. The present study examines the reliability and validity of a Hebrew version of the CAMCOG in a group of dementia sufferers in a clinical setting. METHOD: Study participants included 36 dementia sufferers and 19 control non-demented, depressed elderly subjects, consecutive referrals to an outpatient psychogeriatric service and an 'open' ward of a psychiatric hospital. Operational clinical criteria for dementia and its subtypes and for the various forms of depression were used as the 'gold' standards. The CAMCOG was translated into Hebrew and then back to English. Seven items needed modifications for local usage. RESULTS: Interrater and test-retest scores calculated as exact agreement rates ranged from good to excellent for all items, although test-retest reliability scores were generally lower than interrater scores. Kappa statistics ranged from good to excellent for all but one item in the interrater scores and for two items in the test-retest scores. A strong convergent validity was found with the MMSE score (r=0.89, p<0.01). The 79/80 cutoff point provided moderate sensitivity (57.9%), excellent specificity (97.2%) and a strong predictive value (83.6%). CONCLUSION: The Hebrew version of the CAMCOG was found to be an appropriate instrument to discriminate between demented and non-demented depressed controls in a clinical setting. In light of the demographic, cultural and linguistic heterogeneity of the Israeli elderly population, further studies should examine the psychometric characteristics of the CAMCOG in a more varied sample and also using other cutoff points in order to establish if an increase in its discriminatory power is obtainable.     

The relationship between cognitive function and agitation in senior day care participants

The relationship between cognitive impairment and functional status with agitation was assessed in 200 participants of senior day care programs. Results revealed better than 85% agreement in measures of cognitive impairment (BCRS, MMSE, physician assessment of dementia). Regression analyses showed that physically non-aggressive and verbally aggressive behaviors were related to level of cognitive impairment (BCRS, MMSE). These results showed that physically non-aggressive behaviors were manifested at earlier stages of dementia than physically aggressive behaviors, which were not manifested until late stages of dementia. Verbally non-aggressive behaviors increased with severity of dementia up to moderate-severe levels of impairment and then diminished. In contrast, verbally aggressive behaviors tended to be manifested fairly consistently across levels of dementia with a small increase at the severest levels. Findings are discussed in relation to previous findings for nursing home residents.     

Life events and cognition in dementia

Stresses such as relocation and life events can lead to deterioration in dementia. However it is not known how the severity of dementia influences the occurrence or impact of such stress. This study investigated the relationship between severity of dementia, life events in the preceding six months, and hospital admission. Seventy elderly patients with senile dementia admitted to a geriatric psychiatry unit were compared with 50 dementia sufferers in the community. In general, mild dementia sufferers tended to have a higher frequency of severe threat independent life events. Life events appeared to increase the relative risk of admission for people with less severe dementia, but only when the relatives' accounts of cognitive impairment were used (CAPE & ADS) rather than GMSS rated cognitive impairment. Logistic regression suggested that sensitivity to the effects of threatening life events may be inversely related to the severity of cognitive deficit, but only for the CAPE rating. Clinician's should be aware that dementia sufferers may be particularly sensitive to the effects of psychosocial stress.     

The short test of mental status. Correlations with standardized psychometric testing

The Short Test of Mental Status can be administered to patients in inpatient and outpatient settings in approximately 5 minutes, and it contains items that test orientation, attention, immediate recall, arithmetic, abstraction, construction, information, and delayed (approximately 3 minutes) recall. The test was administered to a group of demented community patients and their age- and sex-matched control subjects. Using an age-adjusted approach, sensitivity of the test to identifying dementia is 86.4, with a specificity of 93.5. The test was compared with standardized tests of cognitive function such as the Wechsler Adult Intelligence Scale, Mattis Dementia Scale, and the Auditory Verbal Learning Test, and showed a high degree of correlation. Group means and standard deviations for subtest items and total score are presented for control subjects (n = 138), demented patients (n = 130), and patients with memory impairment only (n = 20). Percentile scores for subtest items in control subjects are also provided.