Vascular Dementia: Distinguishing Characteristics, Treatment, and Prevention

Vascular dementia (VaD) is the second-most-common cause of dementia in the elderly, after Alzheimer's disease (AD). VaD is defined as loss of cognitive function resulting from ischemic, hypoperfusive, or hemorrhagic brain lesions due to cerebrovascular disease or cardiovascular pathology. Diagnosis requires the following criteria: cognitive loss, often predominantly subcortical; vascular brain lesions demonstrated by imaging; a temporal link between stroke and dementia; and exclusion of other causes of dementia. Poststroke VaD may be caused by large-vessel disease with multiple strokes (multiinfarct dementia) or by a single stroke (strategic stroke VaD). A common form is subcortical ischemic VaD caused by small-vessel occlusions with multiple lacunas and by hypoperfusive lesions resulting from stenosis of medullary arterioles, as in Binswanger's disease. Unlike with AD, in VaD, executive dysfunction is commonly seen, but memory impairment is mild or may not even be present. The cholinesterase inhibitors used for AD are also useful in VaD. Prevention strategies should focus on reduction of stroke and cardiovascular disease, with attention to control of risk factors such as hypertension, diabetes mellitus, hypercholesterolemia, and hyperhomocysteinemia.     

Ecological,convergent, and discriminative validities of the cognitive abilities screening instrument in people with dementia

Background:The Cognitive Abilities Screening Instrument (CASI) assesses global cognitive function in people with dementia with 9 domains (i.e., long-term memory, short-term memory, concentration, orientation, attention, abstraction and judgment, language abilities, visual construction, and category fluency). However, the ecological, convergent, and discriminant validities of the CASI have not yet been examined.Purpose:This study designed to investigate these 3 validities of the CASI in people with dementia.Methods:Fifty-eight participants underwent assessments with the CASI, 3 functional measures, and 3 cognitive measures. Pearson''s r was used to estimate correlations among the CASI and 3 functional measures for examining ecological validity. We computed correlations (r) among the CASI and 3 functional measures for examining convergent validity. An independent t-test was applied to compare the levels of disability, and ceiling/floor effects were analyzed for examining discriminative validity.Results:The CASI total score and domains had moderate to high correlations with 3 functional measures (r = 0.42–0.80), except in 2 CASI domains (i.e., attention and language). The CASI total score and domains showed moderate to high correlations with 3 cognitive measures (r = 0.45–0.93). The t-test results revealed significant differences (P < .05) in the CASI total score and other domains except for the short-term memory domains. Four domains of the CASI showed noticeable ceiling effects (22.4–39.7%).Conclusions:The CASI has adequate ecological validity, good convergent validity, and acceptable discriminative validity in people with dementia. The 5 domains with nonsignificant differences or ceiling effects should only be used with caution to distinguish people with dementia.     

Mixed dementia: epidemiology,diagnosis, and treatment

Alzheimer's disease (AD) and vascular dementia (VaD) are the most frequent causes of dementia in older people. Although AD can be diagnosed with a considerable degree of accuracy, the distinction between isolated AD, VaD, and mixed dementia (MD), where both pathologies coexist in the same patient, remains a controversial issue and one of the most difficult diagnostic challenges. Although MD represents a very frequent pathology, especially in older people, as reported in neuropathological studies, the respective importance of degenerative and vascular lesions, their interaction in the genesis of dementia, and the mere existence of MD are still debated. Accurate diagnosis of MD is of crucial significance for epidemiological purposes and for preventive and therapeutic strategies. Until recently, pharmacological studies have generally focused on pure disease, AD or VaD, and have provided little information on the best therapeutic approach to MD. This article provides an overview of MD in older people. A retrospective review of the recent literature on prevalence, incidence, course, risk factors, diagnosis, and treatment of MD was performed. The article also emphasizes the need for further studies, including neuropsychological and functional evaluations, and neuroimaging and clinicopathological correlations to develop a better understanding of MD, which appears to be one of the most common forms of dementia.     

Mortality, Dementia, and Apolipoprotein E Genotype in Elderly White Women in the United States

OBJECTIVES: To assess the risk of death in relation to apolipoprotein E (APOE) genotype and to evaluate how APOE genotype interacts with dementia and with other major medical conditions to affect survival.
DESIGN: A 6-year prospective cohort study of dementia, APOE genotype and survival.
SETTING: Health maintenance organization in southern California.
PARTICIPANTS: One thousand eight hundred forty-two white women aged 75 and older.
MEASUREMENTS: Dementia was determined using a multistage assessment procedure, medical record, and death certificate review.
RESULTS: With women with the APOE 3/3 genotype as the referent, age-adjusted hazard ratios (HRs) for death according to genotype were 1.25 (95% confidence interval (CI)=1.00–1.56) for APOE 2/4, 3/4, or 4/4 and 0.83 (95% CI=0.62–1.13) for APOE 2/3 or 2/2. Survival was associated with APOE genotype (log rank test P =.02). Women with the APOE 2/4, 3/4, or 4/4 genotype died at an earlier age, and those with APOE 2/2 or 2/3 died later than those with the APOE 3/3 genotype. After adjustment for age, education, and hormone use, HRs for death were significantly higher in women with the APOE 2/4, 3/4, or 4/4 genotype who developed dementia (HR=3.74; 95% CI=2.81–4.99) and the APOE 2/3 genotype (HR=3.23; 95%=CI=1.97–5.28) than in women without dementia and the APOE 3/3 genotype. The HRs for death were greater with other medical conditions, but no interaction with any APOE genotype was found.
CONCLUSION: In this population of elderly women, although having at least one ɛ4 allele increased the chances of an earlier death, having dementia increased the risk of death regardless of APOE genotype.     

Incidence of dementia,Alzheimer's disease,and vascular dementia in Italy. The ILSA Study

OBJECTIVES: To estimate the incidence of dementia, Alzheimer's disease (AD), and vascular dementia (VaD) in older Italians and evaluate the relationship of age, gender, and education to developing dementia. DESIGN: Cohort incidence study in the context of the Italian Longitudinal Study on Aging. SETTING: Population sample from eight Italian municipalities. PARTICIPANTS: A dementia-free cohort of 3,208 individuals (aged 65-84), individuated after a baseline evaluation performed in 1992 / 93, aimed at detecting prevalent cases. MEASUREMENTS: The dementia-free cohort was reexamined in 1995 to identify incident cases. The Mini-Mental State Examination (cutoff 23 / 24) was employed to screen for dementia. Trained neurologists evaluated the individuals who screened positive. Final diagnoses had to meet Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised criteria for dementia, National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association criteria for AD, and International Classification of Diseases, Tenth Revision criteria for VaD. RESULTS: Before the follow-up examination, 382 individuals had died (232 had reliable information). Of the 2,826 survivors, 2,266 completed the study. Overall, 127 new dementia cases were identified. Average incidence rates per 1,000 person-years were 12.47 (95% confidence interval (CI)=10.23-14.72) for dementia, 6.55 (95% CI=4.92-8.17) for AD, and 3.30 (95% CI=2.14-4.45) for VaD. Both AD and VaD showed age-dependent patterns. Education was protective against dementia and AD. Women carried a significantly higher risk of developing AD (hazard ratio=1.67, 95% CI=1.02-2.75), and men of developing VaD (hazard ratio=2.23, 95% CI=1.06-4.71). CONCLUSIONS: Incidence of dementia in Italy paralleled that in most industrialized countries. About 150,000 new cases per year are expected. A significant gender effect was evidenced for major dementia subtypes. The burden of VaD, especially in men, offers opportunities for prevention.     

Rapid Screening of Cognitive Change in Patients with Questionable Dementia Using the Memory Impairment Screen and the Isaacs Set Test

OBJECTIVES: To assess the efficacy of combining the Memory Impairment Screen (MIS) and the Isaacs Set Test (IST) in predicting short-term development of dementia in a group of people with questionable dementia (QD) at baseline.
DESIGN: Performances of the weighted sum of MIS and IST and the ≪or≫ rule were compared with each other and with the Mini-Mental State Examination.
SETTING: Database of the Regional Network for Diagnostic Aid and Management of Patients with Cognitive Impairment in the Franche-Comté geographical area in France.
PARTICIPANTS: A cohort of 106 patients aged 65 and older with QD were followed up for a mean of 14.9 months (range 6–24 months).
MEASUREMENTS: Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the combination of these two tests.
RESULTS: The weighted sum had a sensitivity of 0.74 and a specificity of 0.84. The ≪or≫ rule (MIS<6 or IST<25) had a sensitivity of 0.74 and a specificity of 0.81. When range values were applied, low scores on the MIS and the IST (MIS<6 and IST<25) led to a high probability of dementia, whereas high scores (MIS>7 and IST>29) suggested a high probability of remaining dementia-free in the study follow-up.
CONCLUSION: This quickly performed tool (5 minutes) is simple to use and score. When including cutscores (MIS<6 or IST<25) or range values, this test could be considered a useful screening procedure for all types of dementias.     

The Maryland Assisted Living Study: prevalence, recognition, and treatment of dementia and other psychiatric disorders in the assisted living population of central Maryland

OBJECTIVES: To obtain a direct estimate of the prevalence of dementia and other psychiatric disorders in residents of assisted living (AL) in Central Maryland, and their rates of recognition and treatment. DESIGN: Comprehensive review of history and cognitive and neuropsychiatric evaluations using widely accepted instruments in a randomized cohort of AL residents, stratified by facility size. An expert multidisciplinary consensus panel determined diagnoses and appropriateness of treatment. SETTING: Twenty-two (10 large and 12 small) randomly selected AL facilities in the city of Baltimore and seven Maryland counties. PARTICIPANTS: One hundred ninety-eight volunteers who were residents of AL, 75% were aged 80 and older, and 78% were female. Potential participants were randomly chosen by room number. There was a 67% participation rate. MEASUREMENTS: Overall rate of dementia, noncognitive active psychiatric disorders, and recognition and adequate treatment of dementia and psychiatric disorders, as determined by consensus panel. RESULTS: Two-thirds (67.7%) of participants had dementia diagnosable according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (81% small facilities and 63% large). Family or caregivers recognized 78% to 80% of dementias. Seventy-three percent of dementias were adequately evaluated, and 52% were adequately treated. Of the 26.3% of participants who had an active noncognitive psychiatric disorder, 58% to 61% were recognized and 52% adequately treated. CONCLUSION: Dementia and psychiatric disorders are common in AL and have suboptimal rates of recognition and treatment. This may contribute to morbidity and interfere with the ability of residents to age in place.     

Caring for individuals with dementia and cognitive impairment, not dementia: findings from the aging, demographics, and memory study

OBJECTIVES: To compare the characteristics and outcomes of caregivers of adults with dementia with those of caregivers of adults with cognitive impairment, not dementia (CIND). DESIGN: Cross‐sectional. SETTING: In‐home assessment for cognitive impairment and self‐administered caregiving questionnaire. PARTICIPANTS: One hundred sixty‐nine primary family caregivers of participants in the Aging, Demographics, and Memory Study (ADAMS). ADAMS participants were aged 71 and older drawn from the nationally representative Health and Retirement Study. MEASUREMENTS: Neuropsychological testing, neurological examination, clinical assessment, and medical history were used to assign a diagnosis of normal cognition, CIND, or dementia. Caregiving measures included caregiving time, functional limitations, depressive symptoms, physical and emotional strain, caregiving rewards, caregiver health, and demographic characteristics. RESULTS: Dementia caregivers spent approximately 9 hours per day providing care, compared with 4 hours per day for CIND caregivers (P=.001). Forty‐four percent of dementia caregivers exhibited depressive symptoms, compared with 26.5% of CIND caregivers (P=.03). Physical and emotional strains were similar in both groups of caregivers. Regardless of the strains, nearly all caregivers reported some benefits from providing care. Behavioral problems (P=.01) and difficulty with instrumental activities of daily living (P=.01) in persons with CIND partially explained emotional strain experienced by CIND caregivers. For those with dementia, behavioral problems predicted caregiver emotional strain (P<.001) and depressive symptoms (P=.01). CONCLUSION: Although support services are available to dementia caregivers, CIND caregivers also expend considerable time and experience strains. The real caregiver burden of cognitive impairment in the U.S. population may therefore be greatly underestimated if people who have reached the diagnostic threshold for dementia are focused on exclusively.     

Dementia, diagnostic disclosure, and self-reported health status

OBJECTIVES: To investigate the general awareness of cognitive impairment in persons with documented dementia, evaluate the subject's recall of a diagnostic disclosure from a physician and their recollection of the discussion, and determine whether this awareness of cognitive impairment or the recall of diagnostic disclosure is associated with poorer self‐rated health scores. DESIGN: Secondary data analysis. SETTING: Three university‐based clinical referral sites for dementia illnesses. PARTICIPANTS: Convenience sample of 149 patients with a diagnosis of dementia. MEASUREMENTS: Bivariate and logistic regression models with the outcome variables of patient self‐report of memory problems, patient report of being told about memory problems by a physician, and self‐reported health scores. RESULTS: Ninety‐six of 149 (64.4%) subjects reported that they had memory problems, and this report was independently associated with younger age (P=.01) and higher Mini‐Mental State Examination score (P=.02). Thirty‐nine (26.2%) subjects reported being told by a physician about a diagnosis of dementia or memory problems. This recall was associated with younger age (P<.001), male sex (P=.04), and higher education level (P=.02). African Americans reported poorer self‐rated health scores (odds ratio (OR)=2.4, 95% confidence interval (CI)=1.1–5.1). Persons who reported being told by a physician of a diagnosis of dementia were more likely to report poorer self‐rated health (OR=2.5, 95% CI 1.1–5.5). CONCLUSION: Further research is needed to elucidate the relationship between self‐rated health and dementia specifically focusing on the potentially negative effects of diagnostic disclosure on self‐rated health, further identification of factors that contribute to self‐rated health in persons with dementia, and the prognostic value of self‐rated health for persons with dementia.     

A systematic review of the effect of telephone,internet or combined support for carers of people living with Alzheimer’s,vascular or mixed dementia in the community

BackgroundThe objective of this review was to assess the effectiveness of interventions delivered by telephone, internet or combined formats to support carers of community dwelling people living with Alzheimer’s Disease, vascular dementia or mixed dementia.MethodEnglish language literature published up to 2016 was searched. The initial search included: MEDLINE, Cumulative Index to Nursing and Allied Health (CINAHL), and PsycINFO. A second search was conducted using Medical Subject Headings (MeSH) and keywords for eight databases. The review included randomised controlled trials, non-randomised controlled trials, quasi-experimental and pre-post studies from published and grey literature. Studies selected for retrieval were assessed by three independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments.ResultsTwenty-two studies were included in the review of which 13 were studies of telephone-delivered interventions, five were internet-delivered interventions and four were delivered in a combination of telephone and internet formats. In this review the successful outcomes from the combined telephone and internet delivery exceeded that of telephone alone and internet alone. Very few studies addressed programs for specific types of dementia.ConclusionWhen considering the ratio of number of studies to successful outcomes, combined telephone and internet delivery of multicomponent interventions demonstrated relatively more positive outcomes in reducing depression, burden and increasing self-efficacy than telephone alone or internet alone. Further studies are necessary to evaluate the effectiveness of interventions targeted at specific types of dementia and to understand which components of interventions are most effective.     

Combining the Memory Impairment Screen and the Isaacs Set Test: a practical tool for screening dementias

OBJECTIVES: To assess the accuracy of combining the Memory Impairment Screen (MIS) with the Isaacs Set Test (IST) in distinguishing subjects with dementia from controls without dementia. DESIGN: The weighted sum of MIS and IST scores was calculated, and the logical "or" rule combination was performed using two different patient and control samples. Combination results were compared with each test used alone and with Mini-Mental State Examination to detect all types of dementias. SETTING: Database of the Regional Network for Diagnostic Aid and Management of Patients with Cognitive Impairment in the Franche-Comté, France, geographical area. PARTICIPANTS: A cohort of 444 patients with Alzheimer's disease, non-Alzheimer's dementia, and reversible dementia and 311 controls. MEASUREMENTS: Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the combination of these two tests. RESULTS: The weighted sum had overall sensitivities of 0.92 and 0.84 for mild cases, with a specificity of 0.92. The "or" rule had overall sensitivities of 0.92 and 0.89 for mild cases, with a specificity of 0.90. This pairing requires no more than 5 minutes. Its scoring is simple with the "or" rule combination. CONCLUSIONS: The combination of MIS and IST could be a useful tool for screening dementias. The "or" rule combination seems particularly adapted to medical practice.     

History, development, and future of the progressively lowered stress threshold: a conceptual model for dementia care

Behavioral symptoms associated with dementia are a major concern for the person who experiences them and for caregivers who supervise, support, and assist them. The knowledge and skill of formal and informal caregivers affects the quality of care they can provide and their ability to cope with the challenges of caregiving. Nurses are in an excellent position to provide training to empower caregivers with the knowledge and skills necessary to reduce and better manage behaviors. This article reviews advances in geriatric nursing theory, practice, and research based on the Progressively Lowered Stress Threshold (PLST) model that are designed to promote more adaptive and functional behavior in older adults with advancing dementia. For more than 17 years, the model has been used to train caregivers in homes, adult day programs, nursing homes, and acute care hospitals and has served as the theoretical basis for in-home and institutional studies. Care planning principles and key elements of interventions that flow from the model are set forth, and outcomes from numerous research projects using the PLST model are presented.     

Dementias, psychological tests, and neurotransmitters

A preliminary investigation was made of data of intelligence quotient, dementia quotients, objective profile analysis of MAWI (Hungarian standardized version of WAIS) in patients suffering from multi infarct, primary degenerative and alcoholic dementia (MID, PDD, Alc. D). Homovanillic acid (HVA) and 5-hydroxyindole acetic acid (5-HIAA) were measured in lumbar cerebrospinal fluid (CSF) from patients with presenile dementia and senile dementia of Alzheimer's type (PDAT and SDAT) and multi infarct dementia. They were compared to controls and to each other. Alcoholic dementia can be differentiated from other types of dementia mainly by the values of verbal and practical quotients (VQ/PQ), Hewson Index 5 and by the objective profile analysis. MID can hardly be differentiated from PDD, but the objective profile analysis can help, mainly subtests 1 and 3 of MAWI. No decrease was found in the concentrations of HVA and 5-HIAA in lumbar CSF of demented patients compared to controls, but there was an elevation in 5-HIAA concentration.     

Associations between serum homocysteine, holotranscobalamin, folate and cognition in the elderly: a longitudinal study

Abstract. Hooshmand B, Solomon A, Kåreholt I, Rusanen M, Hänninen T, Leiviskä J, Winblad B, Laatikainen T, Soininen H & Kivipelto M (Aging Research Center, Karolinska Institutet, Stockholm, Sweden; KI Alzheimer’s Disease Research Center (KI‐ADRC), Karolinska Institutet, Stockholm, Sweden; National Institute for Health and Welfare (THL), Helsinki, Finland; University of Eastern Finland, Institute of Clinical Medicine, and University Hospital, Kuopio, Finland). Associations between serum homocysteine, holotranscobalamin, folate and cognition in the elderly: a longitudinal study. J Intern Med 2012; 271 : 204–212. Objectives. To examine the associations between serum homocysteine (tHcy), holotranscobalamin (holoTC, the biologically active fraction of vitamin B12) and folate and cognitive functioning in a longitudinal population‐based study of Finnish elderly subjects. Subjects and design. tHcy, holoTC and folate were measured at baseline in 274 dementia‐free subjects aged 65–79 years from the Cardiovascular Risk Factors, Aging and Dementia study. Subjects were re‐examined 7 years later, and global cognition, episodic memory, executive functioning, verbal expression and psychomotor speed were assessed. Results. Higher baseline tHcy levels were associated with poorer performance in global cognition, relative difference: 0.90 [95% confidence interval (CI) 0.81–0.99]; episodic memory: 0.87 (95% CI 0.77–0.99); executive functions: 0.86 (95% CI 0.75–0.98); and verbal expression: 0.89 (95% CI 0.81–0.97) at follow‐up. Increased holoTC levels were related to better performance on global cognition: 1.09 (95% CI 1.00–1.19); executive functions: 1.11 (95% CI 1.01–1.21); and psychomotor speed: 1.13 (95% CI 1.01–1.26). After excluding 20 cases of incident dementia, increased tHcy remained associated with poorer performance in episodic memory, execution functions and verbal expression. Higher holoTC levels tended to be related to better performance in executive functions and psychomotor speed, while elevated serum folate concentrations were significantly related to higher scores in global cognition and verbal expression tests. Conclusions. tHcy, holoTC and folate levels are related to cognitive performance 7 years later even in nondemented elderly subjects. Randomized trials are needed to determine the impact of vitamin B12 and folate supplementation on preventing cognitive decline in the elderly.