The Treatment of Hypertension in Care Home Residents: A Systematic Review of Observational Studies

AimTo describe the prevalence of hypertension in care home residents, its treatment, change in treatment over time, and the achievement of blood pressure (BP) control.MethodThe PubMed, Cochrane, Embase, and PsychINFO databases were searched for observational studies involving care home residents with a diagnosis of hypertension. The search was limited to English language articles involving adults and humans published from 1990 onward. Abstracts and titles were reviewed with eligible articles read in full. Bibliographies were examined for further relevant studies. The final selection of studies was then analyzed and appraised.ResultsSixteen articles were identified for analysis, of which half were studies carried out in the United States. The prevalence of hypertension in care home residents was 35% (range 16%–71%); 72% of these were on at least 1 antihypertensive (mean 1.5 antihypertensives per individual), with diuretics being the most common. The prevalence of hypertension in study populations was greater in more recent studies (P = .004). ACEi/ARBs (P = .001) and β-blockers (P = .04) were prescribed more frequently in recent studies, whereas use of calcium-channel blockers and diuretics remained unchanged over time. The number of antihypertensives prescribed per patient was higher (correlation 0.332, P = .009), whereas fewer patients achieved target BP (correlation −0.671, P = .099) in more recent studies.ConclusionHypertension is common in care home residents and is commonly treated with antihypertensive drugs, which were prescribed more frequently in more recent studies but with no better BP control. These studies indicate a tendency toward increasing polypharmacy over time, with associated risk of adverse events, without demonstrable benefit in terms of BP control.     

The Informant AD8 Can Discriminate Patients with Dementia From Healthy Control Participants in an Asian Older Cohort

ObjectivesThe informant-AD8 (i-AD8) was found to be reliable in detecting cognitive impairment and dementia in tertiary and primary health care settings. We evaluated the discriminability of the i-AD8, as compared to other brief cognitive measures, and its combination with the 5-minute Montreal Cognitive Assessment (MoCA) and Mini-Cog in detecting very mild dementia in an Asian older cohort.DesignThe Epidemiology of Dementia in Singapore (EDIS) study recruited participants from a population-based eye disease study who were of Chinese, Malay, and Indian ethnicities.Setting and ParticipantsParticipants aged ≥60 years were clinically assessed and diagnosed using the Clinical Dementia Rating (CDR) scale. Of the 761 participants recruited, 526 (69.1%) had no dementia (CDR = 0), 193 (25.4%) had very mild dementia (CDR = 0.5), and 42 (5.5%) had dementia (CDR ≥ 1).MeasuresParticipants were administered the Mini-Mental State Examination, MoCA, Mini-Cog, and a local neuropsychological battery. Their informants were interviewed using the i-AD8. Receiver operating characteristic analyses were conducted to establish the optimal cut-off points, and all discriminatory indices were calculated.ResultsThe i-AD8 was good and equivalent to other cognitive tools in detecting dementia [area under the curve (AUC) = 0.89, sensitivity = 0.76, and specificity = 0.94] but only fair in detecting very mild dementia (AUC = 0.69, sensitivity = 0.62, and specificity = 0.73). Combination of the i-AD8 with 5-minute MoCA or Mini-Cog in compensatory or in conjunction showed minimal improvement to the clinical utility for dementia or very mild dementia. All scales yielded a high rate of false positives (positive predictive value < 0.70).Conclusions and ImplicationsThe i-AD8 has good discriminatory power in detecting dementia (CDR ≥ 1) and is brief enough to be applied as an effective screening tool in the community. However, the i-AD8 and other cognitive tools lacked classification accuracy in detecting very mild dementia (CDR = 0.5).     

Discontinuation of Antihypertensive Medication,Cognitive Complaints,and Incident Dementia

ObjectivesTo evaluate whether discontinuation of antihypertensive medication in community-dwelling older people is associated with a reduction in memory complaints and/or incident dementia.DesignProspective observational cohort study within the Prevention of Dementia by Intensive Vascular Care (preDIVA) trial.Setting and ParticipantsCommunity-dwelling participants (aged 70-78 years at baseline) who underwent 2-yearly assessments during 6-8 years of follow-up.MeasuresCox regression analyses of the relation between discontinuation of antihypertensive medication during the study and change in subjective memory complaints, incident dementia, and mortality.ResultsDementia occurred more often in participants discontinuing antihypertensive treatment (13.4% vs 6.2%, P = .02); mortality was similar (16.5% vs 13.9%, P = .52). Discontinuation of antihypertensive medication was associated with a double dementia hazard [hazard ratio (HR) (95% confidence interval) = 2.15 (1.15-4.03)], which somewhat attenuated after adjustment for sex, blood pressure, number of antihypertensives and other medications [HR = 1.92 (1.01-3.65)], and additionally for stroke, cardiovascular disease, diabetes, smoking, memory complaints, and MMSE score [HR = 1.79 (0.93-3.44)]. Antihypertensive discontinuation was associated with an approximately 50% higher hazard of dementia and/or mortality combined [HR = 1.58 (1.04-2.40); model 2: HR = 1.64 (1.07-2.51); model 3: HR = 1.49 (0.96-2.30)]. Antihypertensive discontinuation was not associated with change in memory complaints [odds ratio (95% confidence interval) = 0.96 (0.55-1.67)]. Subgroup and sensitivity analyses addressing possible sources of bias and confounding gave similar results.Conclusions/ImplicationsOur results suggest that antihypertensive withdrawal in community-dwelling older people does not preserve cognition and may in fact increase dementia risk. This is not due to reduced mortality as competing risk. Additional analyses suggest results are unlikely to be explainable by confounding, reverse causality, or observational biases. Studies with person-specific reasons for antihypertensive discontinuation may be able to exclude reverse causality completely. Given the beneficial effects of antihypertensive medication on cardiovascular risk, observational data may be the best currently obtainable on the pressing issue of when withdrawal of antihypertensives in older people is acceptable and what consequences need to be weighed.     

Antihypertensive Medication Classes and the Risk of Dementia: A Systematic Review and Network Meta-Analysis

ObjectivesTo systematically review and synthesize the evidence on differential associations between antihypertensive medication (AHM) classes and the risk of incident dementia.DesignSystematic review and random effects frequentist network meta-analysis. Embase, MEDLINE, and the Cochrane library were searched from origin to December 2019.Setting and participantsRandomized controlled trials (RCTs) and prospective cohort studies that compared associations of different AHM classes with incident all-cause dementia and/or Alzheimer's disease over at least 1 year of follow-up.MeasuresAll cause dementia and/or Alzheimer's disease.ResultsFifteen observational studies and 7 RCTs were included. Data on AHM classes were available for 649,790 participants and dementia occurred in 19,600 (3.02%). Network meta-analysis showed that in observational studies, treatment with either calcium channel blockers (CCBs) or angiotensin II receptor blockers (ARBs) was associated with lower dementia risks than treatment with other antihypertensives: CCBs vs angiotensin converting enzyme inhibitors (ACE inhibitors) (HR=0.84, 95% CI 0.74-0.95), beta blockers (HR=0.83, 95% CI 0.73-0.95) and diuretics (HR=0.89, 95% CI 0.78-1.01) and ARBs vs ACE inhibitors (HR=0.88, 95% CI 0.81-0.97), beta blockers (HR=0.87, 95% CI 0.77-0.99), and diuretics (HR=0.93, 95% CI 0.83-1.05). There were insufficient RCTs to create a robust network based on randomized data alone.Conclusions and ImplicationsRecommending CCBs or ARBs as preferred first-line antihypertensive treatment may significantly reduce the risk of dementia. If corroborated in a randomized setting, these findings reflect a low-cost and scalable opportunity to reduce dementia incidence worldwide.     

Antihypertensive Medication Regimen Intensity and Incident Dementia in an Older Population

Objective

To investigate the association between antihypertensive medication regimen intensity and risk of incident dementia in an older population.

Visit-to-Visit Blood Pressure Variability and Progression of White Matter Hyperintensities Among Older People With Hypertension

ObjectivesVisit-to-visit blood pressure (BP) variability is a risk factor for cardiovascular disease and cognitive decline. Our aim was to assess the association between visit-to-visit BP variability and progression of white matter hyperintensities (WMH).DesignPost-hoc analysis in the magnetic resonance imaging substudy of the randomized controlled trial prevention of dementia by intensive vascular care.Setting and participantsCommunity-dwelling people age 70–78 years with hypertension.MethodsParticipants had 3 to 5 twice yearly BP measurements and 2 magnetic resonance imaging scans at 3 and 6 years follow-up. We used linear regression adjusted for age, sex, WMH at scan 1, (change in) total brain volume, and cardiovascular risk factors.ResultsAmong the 122 participants, there was a modest association between visit-to-visit systolic BP variability and WMH progression [beta = 0.03 mL/y per point increase in variability, 95% confidence interval (CI) 0.00–0.05, P = .058]. Additional adjustment for slope in systolic BP reduced the associated P value to .043. Visit-to-visit diastolic BP variability was not associated with WMH progression (beta = 0.01 mL/y, 95% CI ?0.02 to 0.03, P = .68). Visit-to-visit pulse pressure variability was associated with WMH progression (beta 0.03 mL/y, 95% CI 0.01–0.05, P < .01).ConclusionsHigher visit-to-visit systolic BP and pulse pressure variability is associated with more progression of WMH among people age 70–78 years with hypertension.ImplicationsInterventions to reduce visit-to-visit BP variability may be most effective in people with low WMH burden.     

Symptom Clusters of Neuropsychiatric Symptoms in Mild Cognitive Impairment and Their Comparative Risks of Dementia: A Cohort Study of 8530 Older Persons

ObjectivesNeuropsychiatric symptoms (NPS) have been recognized to increase the risk of dementia among individuals with mild cognitive impairment (MCI). However, it is unclear whether the risk is shared across the various NPS or driven primarily by selected few symptoms. This study sought to provide confirmatory evidence on the comparative risk of dementia across the various NPS in MCI.DesignCohort study (median follow-up 4.0 years; interquartile range 2.1–6.4 years).SettingAlzheimer's Disease Centers across the United States.ParticipantsParticipants ≥60 years of age and diagnosed with MCI at baseline (n = 8530).MeasuresParticipants completed the Neuropsychiatric Inventory–Questionnaire at baseline and were followed up almost annually for incident dementia. Symptom clusters of NPS, as identified from confirmatory factor analyses, were included in Cox regression to investigate their comparative risks of dementia.ResultsThree symptom clusters of NPS were identified among participants with MCI, namely hyperactivity, affective, and psychotic symptoms. The risk of dementia was present among participants with affective symptoms [hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.4–1.9] and psychotic symptoms (HR 1.6, 95% CI 1.2–2.2), but not among those with hyperactivity symptoms (HR 1.1, 95% CI 0.9–1.3). The risk was higher when affective symptoms and psychotic symptoms co-occurred (HR 2.5, 95% CI 2.0–3.2), with one-half of the participants in this group developing dementia within 2.7 years of follow-up.Conclusions and ImplicationsThe findings illustrate the potential usefulness of NPS as a convenient prognostic tool in the clinical management of MCI. They also suggest the need for future research to focus on affective/psychotic symptoms in MCI when studying the neurobiological links between NPS and neurodegenerative processes.     

High-Intensity Telemedicine Reduces Emergency Department Use by Older Adults With Dementia in Senior Living Communities

ObjectivesIndividuals with dementia have high rates of emergency department (ED) use for acute illnesses. We evaluated the effect of a high-intensity telemedicine program that delivers care for acute illnesses on ED use rates for individuals with dementia who reside in senior living communities (SLCs; independent and assisted living).DesignWe performed a secondary analysis of data for patients with dementia from a prospective cohort study over 3.5 years that evaluated the effectiveness of high-intensity telemedicine for acute illnesses among SLC residents.Setting and participantsWe studied patients cared for by a primary care geriatrics practice at 22 SLCs in a northeastern city. Six SLCs were selected as intervention facilities and had access to patient-to-provider high-intensity telemedicine services to diagnose and treat illnesses. Patients at the remaining 15 SLCs served as controls. Participants were considered to have dementia if they had a diagnosis of dementia on their medical record problem list, were receiving medications for the indication of dementia, or had cognitive testing consistent with dementia.MeasuresWe compared the rate of ED use among participants with dementia and access to high-intensity telemedicine services to control participants with dementia but without access to services.ResultsIntervention group participants had 201 telemedicine visits. In participants with dementia, it is estimated that 1 year of access to telemedicine services is associated with a 24% decrease in ED visits (rate ratio 0.76, 95% confidence interval 0.61, 0.96).Conclusions/ImplicationsTelemedicine in SLCs can effectively decrease ED use by individuals with dementia, but further research is needed to confirm this secondary analysis and to understand how to best implement and optimize telemedicine for patients with dementia suffering from acute illnesses.     

Antihypertensive Deprescribing in Older Adult Veterans at End of Life Admitted to Veteran Affairs Nursing Homes

ObjectivesGeriatric palliative care approaches support deprescribing of antihypertensives in older nursing home (NH) residents with limited life expectancy and/or advanced dementia (LLE/AD) who are intensely treated for hypertension (HTN), but information on real-world deprescribing patterns in this population is limited. We examined the incidence and factors associated with antihypertensive deprescribing.DesignNational, retrospective cohort study.Setting and ParticipantsOlder Veterans with LLE/AD and HTN admitted to VA NHs in fiscal years 2009-2015 with potential overtreatment of HTN at admission, defined as receiving at least 1 antihypertensive class of medications and mean daily systolic blood pressure (SBP) <120 mm Hg.MeasuresDeprescribing was defined as subsequent dose reduction or discontinuation of an antihypertensive for ≥7 days. Competing risk models assessed cumulative incidence and factors associated with deprescribing.ResultsWithin our sample (n = 10,574), cumulative incidence of deprescribing at 30 days was 41%. Veterans with the greatest level of overtreatment (ie, multiple antihypertensives and SBP <100 mm Hg) had an increased likelihood (hazard ratio 1.75, 95% confidence interval 1.59, 1.93) of deprescribing vs those with the lowest level of overtreatment (ie, one antihypertensive and SBP ≥100 to <120 mm Hg). Several markers of poor prognosis (ie, recent weight loss, poor appetite, dehydration, dependence for activities of daily living, pain) and later admission year were associated with increased likelihood of deprescribing, whereas cardiovascular risk factors (ie, diabetes, congestive heart failure, obesity), shortness of breath, and admission source from another NH or home/assisted living setting (vs acute hospital) were associated with decreased likelihood.Conclusions and ImplicationsReal-world deprescribing patterns of antihypertensives among NH residents with HTN and LLE/AD appear to reflect variation in recommendations for HTN treatment intensity and individualization of patient care in a population with potential overtreatment. Factors facilitating deprescribing included treatment intensity and markers of poor prognosis. Comparative effectiveness and safety studies are needed to guide clinical decisions around deprescribing and HTN management.     

Comparison of different collection methods for reported adverse events following pandemic and seasonal influenza vaccination

BackgroundDuring the 2009/2010 season, information on adverse events after administration of seasonal and pandemic influenza vaccines was collected by different active surveys in the Netherlands. In the present paper, we compared data from a paper-based questionnaire with data from a web-based questionnaire with respect to outcomes and target population, in order to guide future influenza vaccine safety monitoring.MethodsThe paper-based survey collected data from patients who attended primary care practices in the province of Utrecht for influenza vaccination. The web-based survey recruited participants from the general population all provinces of the Netherlands. To analyze the association between study approach and the reported local and systemic adverse events, a generalized estimation equation model was applied. We adjusted for age, gender, comorbidity, previous vaccination and socio-economic status score.ResultsNo significant differences were found between the two studies approaches in reporting local reactions (OR: 0.98, 95% CI 0.88–1.10) and systemic AEs (OR: 1.12, 95% CI 0.99–1.27). There were important differences in the age groups that responded. The elderly were more represented in the paper-based survey where participants were recruited via GPs (79% ⩾ 60 years) compared to 37% in the web-based survey where participants were recruited via internet.ConclusionThe paper-based survey with recruitment of participants through GPs is more representative for the target group of influenza vaccination compared to the web-based survey with recruitment of participants via internet. A web-based approach with recruitment of participants via internet seems more suitable for situations where information about adverse events on a national level is desirable. We recommend to recruit participants for a web-based survey during mass vaccinations sessions by GPs to comply with the recommendations of the European Centre for Disease Prevention Control.     

The Optimal Short Version of Montreal Cognitive Assessment in Diagnosing Mild Cognitive Impairment and Dementia

ObjectivesWhile various short variants of the Montreal Cognitive Assessment (MoCA) have been developed, they have not been compared among each other to determine the most optimal variant for routine use. This study evaluated the comparative performance of the short variants in identifying mild cognitive impairment or dementia (MCI/dementia).DesignBaseline data of a cohort study.SettingAlzheimer's Disease Centers across the United States.ParticipantsParticipants aged ≥50 years (n = 4606), with median age 70 (interquartile range 65-76).MeasuresParticipants completed MoCA and were evaluated for MCI/dementia. The various short variants of MoCA were compared in their performance in discriminating MCI/dementia, using areas under the receiver operating characteristic curve (AUCs).ResultsAll 7 short variants of MoCA had acceptable performance in discriminating MCI/dementia from normal cognition (AUC 87.7%-91.0%). However, only 2 variants by Roalf et al (2016) and Wong et al (2015) demonstrated comparable performance (AUC 88.4-88.9%) to the original MoCA (AUC 89.3%). Among the participants with higher education, only the variant by Roalf et al had similar AUC to the original MoCA. At the optimal cut-off score of <25, the original MoCA demonstrated 84.4% sensitivity and 76.4% specificity. In contrast, the short variant by Roalf et al had 87.2% sensitivity and 72.1% specificity at its optimal cut-off score of <13.Conclusions/implicationsThe various short variants may not share similar diagnostic performance, with many limited by ceiling effects among participants with higher education. Only the short variant by Roalf et al was comparable to the original MoCA in identifying MCI or dementia even across education subgroups. This variant is one-third the length of the original MoCA and can be completed in <5 minutes. It provides a viable alternative when it is not feasible to administer the original MoCA in clinical practice and can be especially useful in nonspecialty clinics with large volumes of patients at high risk of cognitive impairment (such as those in primary care, geriatric, and stroke prevention clinics).     

Effectiveness of Powerful Tools for Caregivers on Caregiver Burden and on Care Recipient Behavioral and Psychological Symptoms of Dementia: A Randomized Controlled Trial

ObjectiveThe aim of this study was to evaluate the effectiveness of a psychoeducational intervention, Powerful Tools for Caregivers (PTC), for family caregivers of individuals with dementia.DesignA pragmatic, 2-arm randomized controlled trial compared the PTC intervention, as delivered in practice, to usual care. Participants randomized to usual care functioned as a control group and then received the PTC intervention.InterventionPTC is a 6-week manualized program that includes weekly 2-hour classes in a group setting facilitated by 2 trained and certified leaders. The educational program helps caregivers to enhance self-care practices and manage emotional distress.Setting and participantsTwo stakeholder organizations delivered the intervention in community settings. Participants were family caregivers of individuals with dementia recruited from the community in Florida.MethodsPrimary outcomes were caregiver burden and behavioral and psychological symptoms of dementia of the care recipient. Secondary outcomes included caregiver depressive symptoms, self-efficacy, self-rated health, and life satisfaction. Measures were collected at baseline (n = 60 participants), postintervention (n = 55), and at 6-week follow-up (n = 44).ResultsIntent-to-treat analyses found PTC reduced caregiver burden (d = −0.48) and depressive symptoms (d = −0.53), and increased self-confidence (d = 0.68), but found no significant benefit for behavioral and psychological symptoms of dementia in care recipients. PTC was rated highly by participants and program attrition was low, with 94% of caregivers completing at least 4 of the 6 classes.Conclusions and implicationsAlthough no significant effects were found for behavioral and psychological symptoms of dementia, this trial supports the effectiveness of PTC to improve caregiver outcomes as delivered in the community.     

中国中年人群超敏C反应蛋白与心血管事件、总死亡事件的关联研究

目的 了解超敏C反应蛋白（hs-CRP）与心血管事件、全因死亡事件是否独立相关。方法 2009-2010年在我国12个研究地区各抽取35~64岁调查对象1 000人,实际入选11 623人。收集清晨空腹血标本检测hs-CRP,同时调查心血管病危险因素。2016-2017年对12个地区中的7个地区进行随访,中位随访时间为6.21年（36 075人年）,并记录心血管和死亡事件。总共随访6 177例,排除基线感染者、未进行hs-CRP检测和体格测量的研究对象后,5 984例纳入最终分析。根据hs-CRP值（mg/L）将人群分为3组（<1、1~和>3）。使用Cox比例风险模型,在调整各混杂因素后,探讨hs-CRP与心血管事件及总死亡事件的关联。结果 随访对象平均年龄50.2岁。hs-CRP<1、1~和>3 mg/L 3组人群心血管事件的发生率分别为3.6/1 000人年、7.1/1 000人年和10.4/1 000人年;全因死亡事件发生率分别为3.0/1 000人年、5.7/1 000人年和9.1/1 000人年。调整混杂因素后,与hs-CRP<1 mg/L组相比,hs-CRP 1~和>3 mg/L明显增加心血管事件的发生风险,HR值（95% CI）分别为1.33（0.95~1.84）和1.76（1.20~2.60）,呈明显上升趋势（趋势检验P=0.003）;发生全因死亡风险也明显增加,HR值（95% CI）分别为1.76（1.23~2.54）和2.64（1.74~4.01）,呈明显上升趋势（趋势检验P<0.001）。结论 hs-CRP增高与心血管事件及全因死亡事件呈独立相关。     

The Effects of Exercise on Falls in Older People With Dementia Living in Nursing Homes: A Randomized Controlled Trial

ObjectivesTo investigate exercise effects on falls in people with dementia living in nursing homes, and whether effects were dependent on sex, dementia type, or improvement in balance. A further aim was to describe the occurrence of fall-related injuries.DesignA cluster-randomized controlled trial.Setting and ParticipantsThe Umeå Dementia and Exercise study was set in 16 nursing homes in Umeå, Sweden and included 141 women and 45 men, a mean age of 85 years, and with a mean Mini-Mental State Examination score of 15.InterventionParticipants were randomized to the high-intensity functional exercise program or a seated attention control activity; each conducted 2-3 times per week for 4 months.MeasuresFalls and fall-related injuries were followed for 12 months (after intervention completion) by blinded review of medical records. Injuries were classified according to severity.ResultsDuring follow-up, 118 (67%) of the participants fell 473 times in total. At the interim 6-month follow-up, the incidence rate was 2.7 and 2.8 falls per person-year in exercise and control group, respectively, and at 12-month follow-up 3.0 and 3.2 falls per person-year, respectively. Negative binomial regression analyses indicated no difference in fall rate between groups at 6 or 12 months (incidence rate ratio 0.9, 95% confidence interval (CI) 0.5–1.7, P = .838 and incidence rate ratio 0.9, 95% CI 0.5–1.6, P = .782, respectively). No differences in exercise effects were found according to sex, dementia type, or improvement in balance. Participants in the exercise group were less likely to sustain moderate/serious fall-related injuries at 12-month follow-up (odds ratio 0.31, 95% CI 0.10–0.94, P = .039).Conclusions/ImplicationsIn older people with dementia living in nursing homes, a high-intensity functional exercise program alone did not prevent falls when compared with an attention control group. In high-risk populations, in which multimorbidity and polypharmacy are common, a multifactorial fall-prevention approach may be required. Encouraging effects on fall-related injuries were observed, which merits future investigations.     

Visual Acuity in Institutionalized Seniors With Moderate to Severe Dementia

ObjectiveThe evaluation of visual acuity (VA) in cognitively impaired older individuals may be limited by a reduced ability to cooperate or communicate. The objective of this research was to assess VA in older institutionalized individuals with cognitive impairment, including severe dementia, using various acuity charts.Design, setting, participants, and measurementsThree groups of 30 participants each were recruited: (1) young participants; (2) older participants with no history of cognitive or communication disorders; and (3) older participants with cognitive impairment, including severe dementia, residing in long term care facilities. The Mini-Mental State Examination was performed for each institutionalized subject. VA was measured using 6 validated charts [Snellen, Teller cards, Early Treatment Diabetic Retinopathy Study (ETDRS)-letters, -numbers, -Patty Pics, -Tumbling Es] presented in random order. Nonparametric tests were used to compare VA scores between charts, after Bonferroni-Holm corrections for multiple comparisons.ResultsParticipants in groups 1 and 2 responded to all charts. A large proportion of participants with dementia responded to all charts (n = 19), whereas only one did not respond to any chart. In group 3, VA charts with the lowest scores were the Teller cards (20/65) and Patty Pics (20/62), regardless of the level of dementia, whereas the highest VA scores were obtained with the Snellen (20/35) and ETDRS-letter (20/36) charts. Across all groups, the ETDRS-letter chart was the only one whose scores did not differ from those obtained with the standard Snellen chart.ConclusionsVisual acuity can be measured, and should at least be attempted, in older cognitively impaired individuals having a reduced ability to communicate.     

Meaningful Activities and Sources of Meaning for Community-Dwelling People Living with Dementia

ObjectivesTo examine how people living with dementia at home engage in meaningful activities, a critical component of quality of life.DesignEthnographic study design using semistructured interviews, participant-observation, and ethnographic analysis.Setting and ParticipantsHome setting. People living with dementia were recruited through 3 geriatrics programs in the San Francisco Bay Area, along with 1 primary live-in care partner for each. Participants were purposively sampled to maximize heterogeneity of dementia severity and life experience.MeasurementsWe asked participants to self-identify and report meaningful activity engagement prior to dementia onset and during the study period using a structured questionnaire, semistructured dyadic interviews, and observed engagement in activities. Home visits were audio-recorded, transcribed, and inductively analyzed using thematic analysis.ResultsTwenty-one people living with dementia (mean age 84 years, 38% women) and 20 care partners (59 years, 85% women), including 40% professionals, 35% spouse/partners, and 15% adult children. Overarching theme: specific activities changed over time but underlying sources of meaning and identity remained stable. As dementia progressed, meaningful activity engagement took 3 pathways. Pathway 1: Activities continued with minimal adaptation when engagement demanded little functional or cognitive ability (eg, watching football on TV). Pathway 2: care partners adapted or replaced activities when engagement required greater functional or cognitive abilities (eg, traveling overseas). This pathway was associated with caregiving experience, nursing training, and strong social support structures. Pathway 3: care partners discontinued meaningful activity engagement. Discontinuation was associated with severe caregiver burden, coupled with illness, injury, or competing caregiving demands severe enough to impact their ability to facilitate activities.Conclusions and ImplicationsFor people living with dementia at home, underlying sources of meaning and identity remains stable despite changes in meaningful activity engagement. Many of the factors associated with adaptation vs discontinuation over time are modifiable and can serve as targets for intervention.     

Sleep Duration and the Risk of Dementia: A Systematic Review and Meta-analysis of Prospective Cohort Studies

ObjectiveEpidemiologic studies have reported inconsistent findings about the association between sleep duration and the risk of dementia. We aimed to clarify this association by method of meta-analysis.DesignSystematic review and meta-analysis of prospective cohort studies.Setting and participantsCommunity or clinical settings. Participants included patients with dementia or Alzheimer's disease and the general population.MeasuresWe systematically searched the PubMed, EMBASE, and Web of Science for prospective cohort studies investigating the association between sleep duration and all-cause dementia or Alzheimer's disease (AD). Generic inverse-variance method was used to combine the outcomes with a random effects model for the association between sleep duration (short or long vs normal) and all-cause dementia or AD.ResultsWe identified 7 studies for all-cause dementia and 6 studies for AD. Pooled analyses showed that long sleep duration was associated with a 77% increased risk of all-cause dementia [hazard ratio (HR) = 1.77, 95% confidence interval (CI) = 1.32-2.37] and a 63% increased risk of AD (HR = 1.63, 95% CI = 1.24-2.13). Short sleep duration was not statistically associated with an increased risk of all-cause dementia (HR = 1.20, 95% CI = 0.91-1.59) or AD (HR = 1.18, 95% CI = 0.91-1.54).Conclusions and implicationsOnly long sleep duration is significantly associated with an increased risk of all-dementia and AD. Future studies are needed to better understand the mechanisms underlying this association.