Self-reported distress after cognitive testing in patients with Alzheimer's disease

Background. The prevalence and degree of self-reported distress that patients with Alzheimer's disease (AD) experience after cognitive testing remain unknown. It is also unknown whether this level of distress is at all related to specific patient factors, test performance, or awareness of test performance. Methods. In 154 mild-to-moderate AD patients and 62 cognitively intact patients, we measured self-reported distress, on a five-point Likert scale, after 45 minutes of cognitive testing. Using multivariate logistic regression, we then examined whether demographic factors, level of education, depressive symptoms, cognitive performance, perceived test difficulty, and perceived test performance compared to 10 years ago were predictive of self-reported distress. Results. The prevalence of any self-reported distress in patients with AD was 70% compared to 47% in patients without AD (p <.001). Of persons with AD, bivariate analyses revealed that those who reported more difficulty with testing (relative risk [RR] 1.32; 95% confidence interval [CI], 1.25-1.37) and felt that they performed worse than 10 years ago (RR 1.21; 95% CI, 1.07-1.30) were at increased risk for reporting more distress. Paradoxically, cognitive performance was a weak predictor of distress, with only language performance demonstrating an association (RR 0.95; 95% CI, 0.89-0.99). Adjustments for demographic factors, education, dementia severity, or depressive symptoms in the multivariable analyses did not alter these relationships. Conclusion. Cognitive tasks provoke more distress in patients with mild-to-moderate AD compared with persons who do not have dementia. Predictors of distress are more closely related to patient awareness about test difficulty and performance, rather than actual test performance.     

Predictors of behavioral disturbance in Alzheimer's disease

The relationship of behavioral disturbances in Alzheimer's disease to disease severity, age at onset, and the presence of extrapyramidal signs was investigated in three studies. Five categories of behavior disturbance were ascertained through structured interview with the patient's primary caregiver: apathy, agitation, psychotic symptoms, disinhibition, and irritability. In Study 1, measures of disease severity accounted for 42% of the variance in the Apathy scale but less than 20% of the variance in the remaining scales. In Study 2, the presence of extrapyramidal signs was associated with increased Apathy and moderated the association between disease severity and the Psychotic Symptoms and Irritability scales. In Study 3, age at onset was associated with the Agitation scale and moderated the association between disease severity and the Apathy, Psychotic Symptoms, and Irritability scales. The findings are discussed in terms of the clinical heterogeneity within Alzheimer's disease, the possible biological bases of these behavioral disturbances, and the psychometric issues pertinent to their measurement.     

Progression of cognitive impairment in Alzheimer's disease

Change in cognitive function was assessed over 12 months in 110 patients over the age of 65 satisfying National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS/ADRDA) criteria for "probable" Alzheimer's Disease. A highly significant deterioration in cognitive function was observed. Decline in cognitive scores was relatively normally distributed. Patients who died during the follow-up had more apraxia at entry to the study than survivors. A greater rate of decline was seen in patients whose parents suffered from dementia (but not in those where a sibling or other relative was affected), in subjects who had moderate dementia, and those who had been ill for less than 24 months. Age, age of onset, and the presence or absence of aphasia or apraxia had no influence on rate of progression. A cluster analysis revealed three patterns of decline.     

Predictors of depressive symptoms in persons with Alzheimer's disease

In a 4-year longitudinal study, we evaluated factors related to the development of depressive symptoms in 410 persons with Alzheimer's disease. We measured depressive symptoms annually by using the 17-item Hamilton Rating Scale, which we completed by using structured interviews with family members. On the basis of informant ratings of premorbid personality, we associated neuroticism with a higher rate of depressive symptoms, particularly mood disturbances. We associated greater cognitive impairment with a small reduction in mood symptoms and a modest increase in somatic symptoms. Among demographic variables, somatic symptoms were more common in men and mood symptoms were inversely related to age. Depressive symptoms in Alzheimer's disease appear to follow a more predictable pattern of expression than previously described.     

Alzheimer's disease and post-operative cognitive dysfunction

Alzheimer's disease (AD), an insidious and progressive neurodegenerative disorder accounting for the vast majority of dementia, is characterized by global cognitive decline and the robust accumulation of amyloid deposits and neurofibrillary tangles in the brain. This review article is based on the currently published literature regarding molecular studies of AD and the potential involvement of AD neuropathogenesis in post-operative cognitive dysfunction (POCD). Genetic evidence, confirmed by neuropathological and biochemical studies, indicates that excessive beta-amyloid protein (Abeta) generated from amyloidogenic processing of the beta-amyloid precursor protein (APP) plays a fundamental role in the AD neuropathogenesis. Abeta is produced from APP by beta-secretase, and then gamma-secretase complex, consisting of presenilins, nicastrin (NCSTN), APH-1 and PEN-2. Additionally, Abeta clearance and APP adaptor proteins can contribute to AD neuropathogenesis via affecting Abeta levels. Finally, cellular apoptosis may also be involved in AD neuropathogenesis. Surgery and anesthesia can cause cognitive disorders, especially in elderly patients. Even the molecular mechanisms underlying these disorders are largely unknown; several perioperative factors such as hypoxia, hypocapnia and anesthetics may be associated with AD and render POCD via trigging AD neuropathogenesis. More studies to assess the potential relationship between anesthesia/surgery and AD dementia are, therefore, urgently needed.     

Predictors of falls among institutionalized women with Alzheimer's disease

Falls among elderly residents are a major concern of facilities caring for the aged. A group of institutionalized women with senile dementia of the Alzheimer type (N = 60; mean age 83) were studied longitudinally and evaluated annually on 21 variables of physical, social, emotional, self-care, and cognitive functioning. A substudy of falls they experienced used data from two such annual evaluations. Clinical ratings by the interdisciplinary team estimated 1) the women's changes in function during the preceding year and 2) the current levels of the women's functioning. Separate regressions for each of the two years returned identical significant patterns indicating that ratings of physical vigor were significantly related to number of falls. Those women who had been among the most vigorous in the group but who had shown significant declines in the preceding year were the most vulnerable to falls; women who had been rated as the least vigorous but whose levels of vigor had been stable during the year tended to have fewer falls. Falling therefore appears to be related to the process of decline in vigor among those in the group whose levels of vigor were higher initially. There were corresponding significant declines in emotional and cognitive scales.     

Mild cognitive impairment and preclinical Alzheimer's disease

Alzheimer's disease (AD) is a progressive neurodegenerative disorder that is characterized by a gradual decline of numerous cognitive processes, culminating in dementia. Mild cognitive impairment (MCI) is a relatively broad clinical condition involving a slight memory deficit, which in many cases represents a transitional state between normal cognition and AD. Much research is currently being conducted on MCI, since any therapy that is effective at treating this early manifestation of dementia may provide an opportunity for managing the disease while patient function is relatively preserved. Current research seeks to develop disease-modifying treatments that intervene in the pathobiologic processes involved in MCI and AD. Another goal of current research is to develop antecedent biomarkers that can be used to detect AD prior to the appearance of symptoms and before substantial and irreversible brain damage occurs.     

Therapeutic pretense in reality orientation

Based on a three month period of intensive observation in a nursing home, this study examines several aspects of the staff's work in the application of reality orientation (RO) to patients who are confused or disoriented. It is argued that in the application of RO and similar behavioral therapies, a clear analytic separation between the problems of patients and the work of caregivers cannot be justified. Caregivers do more than provide care; they help to constitute problems.     

Predictors of institutionalization among caregivers of patients with Alzheimer's disease

The treatment aim of medical care for home-based patients with Alzheimer's disease is to maximize the functioning level of the patient without jeopardizing quality of life for the caregiver. Most demented elderly live in the community with their families who, until coping becomes ineffective, usually prefer to keep their relatives out of institutions for as long as possible. In the present study, the question of why some families continue to shoulder the burden of care, often beyond healthful limits, while others relinquish care to professionals is examined longitudinally in a sample of 209 caregivers. Using logistic regression techniques, caregiver characteristics and caregiver well-being, rather than patient characteristics, emerge as important predictors of placement decisions. Results suggest that practitioners, in evaluating the family's need for institutionalization, must move beyond duration of illness and current cognitive functioning to aspects of the caregiver support system.     

Relation of cognitive status and abnormal behaviors in Alzheimer's disease

Some studies suggest that abnormal behaviors are associated with increasing cognitive loss in Alzheimer's disease (AD). Other studies do not show this association. We examined the relation of cognitive loss, represented by Folstein Mini-Mental State Examination (MMSE) score, with abnormal behaviors in 680 patients with probable AD. Six behaviors were examined: agitation/anger, personality change, wandering, hallucinations/delusions, insomnia, and depression. All but depression were associated with declining MMSE score. The number of abnormal behaviors present in each patient was also related to declining MMSE score. Several other associations were also found: hallucinations/delusions were associated with age and race; agitation/anger was related to male gender; and wandering was associated with increased age. Although these data support the general notion that five of the six abnormal behaviors studied are more likely to occur with increasing cognitive loss, the correlations are small and it is suggested that other as yet unproven factors may play an as large or greater role than MMSE score in predicting such behaviors.     

Early identification of cognitive deficits: preclinical Alzheimer's disease and mild cognitive impairment

With the projected dramatic increase in the number of people who will be diagnosed with Alzheimer's disease (AD) in the coming years, interest is growing in identifying and treating adults at high risk for developing the disorder. Recent research suggests that individuals who will go on to receive a diagnosis of AD exhibit deficits in cognitive performance years beforehand. Those with mild cognitive impairment (MCI), for example, have characteristic cognitive deficits, such as memory loss, and convert to a diagnosis of AD at a faster rate than cognitively healthy controls. MCI has thus become a focus of research because it may help identify high-risk individuals for whom prophylactic treatments designed to slow the progress toward AD can be prescribed. After describing the diagnostic criteria and dementia outcomes associated with MCI, this article discusses several challenges to the study of cognitive impairment before the diagnosis of AD.     

Multiple cognitive deficits during the transition to Alzheimer's disease

The literature on cognitive markers in preclinical AD is reviewed. The findings demonstrate that impairment in multiple cognitive domains is typically observed several years before clinical diagnosis. Measures of executive functioning, episodic memory and perceptual speed appear to be most effective at identifying at-risk individuals. The fact that these cognitive domains are most implicated in normal cognitive aging suggests that the cognitive deficit observed preclinically is not qualitatively different from that observed in normal aging. The degree of cognitive impairment prior to the diagnosis of Alzheimer's disease (AD) appears to generalize relatively well across major study characteristics, including sample ascertainment procedures, age and cognitive status of participants, as well as time to diagnosis of dementia. In episodic memory, there is evidence that the size of the preclinical deficit increases with increasing cognitive demands. The global cognitive impairment observed is highly consistent with observations that multiple brain structures and functions are affected long before the diagnosis of AD. However, there is substantial overlap in the distribution of cognitive scores between those who will and those who will not be diagnosed with AD, hence limiting the clinical utility of cognitive markers for early identification of cases. Future research should consider combining cognitive indicators with other types of markers (i.e. social, somatic, genetic, brain-based) in order to increase prediction accuracy.     

Predictors of burnout in the family caregivers of Alzheimer's disease: Evidence from Turkey

Objective: The aim of this study was to investigate the factors related to burnout in the family caregivers of Alzheimer's disease. Methods: Subjects included in the study were 44 Alzheimer's disease patients and their primary caregivers. Patients were evaluated with Mini Mental State Examination, Brief Psychiatric Rating Scale, Physical Self‐Maintenance Scale and Geriatric Depression Scale, and carers were administered Maslach Burnout Inventory, Ways of Coping Scale, Hamilton Anxiety Rating Scale and Hamilton Depression Rating Scale. Results: The emotional exhaustion of caregivers revealed a significant relationship with the caregivers’ anxiety, submissive approach for coping and the patient's self‐maintenance. Depersonalisation was found to be related to the depression score of the patient. Discussion: This study may serve to increase clinicians’ awareness of burnout in relatives of dementia patients. It points to the fact that research for determining the causes and consequences of burnout in the family caregivers is warranted.