Neurological abnormalities in cognitively impaired but not demented elderly

OBJECTIVE: We determined the prevalence and clinical characteristics of elderly people with cognitively impaired but not demented (CIND) in the community. MATERIAL AND METHODS: We examined 945 elderly residents (aged 65 years or more) in a cross-sectional study of a standardized clinical examination in 27 randomly selected communities in the town of Mifune, a standard farming town in Japan. RESULTS: The prevalence of CIND and dementia were 10.8% and 4.8%, respectively, with both rates increasing with age. The frequency of most neurological signs in CIND elderly was greater than that found in subjects with no cognitive impairment (NCI) and less than that in subjects with dementia. The mean ADL disability score in CIND subjects also lay between the mean values for those with NCI and those with dementia. There were no differences in lifestyles between the CIND group and the other groups. CONCLUSION: The results suggest that a majority of CIND elderly suffer from brain dysfunction due to chronic neurological disorders or aging itself.     

Group reminiscence therapy for cognitive and affective function of demented elderly in Taiwan

BACKGROUND: Elderly people with cognitive impairments are often associated with depressed mood and are heavy consumers in both medical services and need in caregivers. Reminiscence is believed to be effective in improving the cognition and mood of demented people. OBJECTIVES: This study tested the hypothesis that structured group reminiscence therapy can prevent the progression of cognitive impairment and enhance affective function in the cognitively impaired elderly. METHODS: A randomized controlled trial (RCT) based on a two group pre- and post-test design was used. The experimental subjects underwent eight group sessions, one session per week. The measurements were performed using Mini-Mental State Examination (MMSE), Geriatric Depression Scale short form (GDS-SF), and Cornell Scale for Depression in Dementia (CSDD). RESULTS: The sample consisted of 102 subjects, with 51 in the experimental group and 51 in the control group. Results demonstrated that the intervention significantly affected cognitive function and affective function as measured by MMSE and CSDD (p = 0.015 and 0.026), indicating that the cognitive function of the experimental subjects increased and their depressive symptoms diminished following intervention. CONCLUSION: Participation in reminiscence activities can be a positive and valuable experience for demented older persons. Consequently, the development of a structured care program for elderly persons with cognitive impairment and the need for long-term care is essential. Thus, health providers in long-term care facilities should be trained in reminiscence group therapy, and to be able to deliver such a program to the targeted group.     

Predictors of outcomes from a ward for demented elderly: gender differences

Background:  In a previous study, we found gender differences among care recipients and suggested that elderly women living alone have difficulty receiving care from their families. We investigated the gender differences among predictors which influenced outcomes after discharge from a ward for treatment of demented elderly with severe psychotic symptoms.
Methods:  We enrolled the data of 325 patients with dementia who were hospitalized between 1 April 2000 and 31 March 2007, and discharged by 31 March 2008. Two hundred and ninety-four patients were divided into men and women. We checked the gender differences of their characteristics. After that, they were subdivided into three groups to analyze the effect of each patient's characteristics and care situation on their outcomes: (i) given home care (home); (ii) became institutionalized (institution); and (iii) transferred to another hospital (hospital).
Results:  In the hospital groups, the incidence of complications was high for each sex. The differences between the institution group and home group were shown by N-ADL score in men. In contrast, the predictors in women were the HDS-R score, the number of cohabitants and the caregiver.
Conclusions:  It was observed that there were gender differences among outcome predictors. The outcomes of demented patients were predicted by both complications and condition on admission. Most women did not return to their homes because of the situation in which they received care. It is necessary to establish a clear system for providing care for the demented elderly, especially for women.     

Predictors of length of stay in a ward for demented elderly: gender differences

Background: In our previous studies, we found both gender differences among care recipients and predictors that influenced outcomes after discharge from a ward for demented elderly. Here, we investigate predictors that influence the length of stay for each sex. Methods: We studied the data of 390 patients with dementia who were hospitalized in a ward for demented elderly between 1 April 2000 and 31 March 2008, and treated until 31 March 2009. The patients were divided into groups classified by gender. We analyzed the gender differences of characteristics and evaluated the predictors that influenced the length of stay in the ward for demented elderly using Cox's proportional hazards model. A model using the initial scores of the Revised Hasegawa Dementia Scale (HDS‐R), Assessment Scale for Symptoms of Dementia (ASSD) and Nishimura's activity of daily living scale (N‐ADL), which were examined on admission, was named Model 1. In Model 1, we checked the effect of each patient's characteristics, except for complications and destinations, on their length of stay. Model 2 used the final scores of HDS‐R, ASSD and N‐ADL including complications and destinations. Results: There was a clear gender difference in the length of stay. The length of stay of women was longer than that of men. It was difficult to predict the length of stay in Model 1. Age was the only predictor in women and no predictor was identified in men. In Model 2, complications and the final HDS‐R and N‐ADL scores were predictors of the length of stay in men. Age, complications and destinations were predictors of the length of stay in women. Conclusions: It was observed that there were gender differences among predictors of the length of stay. However, it was difficult to predict the length of stay on admission. Retrospectively, the length of stay was determined by physical and psychological conditions, not by the social variables in men. In women, it was supposed that the caregiver's wish to give care at home reduced the length of stay. Besides, complication was a common predictor of the extension of stay in each sex. We have to decrease the number of complications as much as possible to reduce the length of stay.     

Dual-task performance in demented and nondemented elderly

Abstract

The present study examined the ability of demented and nondemented elderly subjects to divide their attention between recalling digits and judging the similarity of pairs of letters. Both groups showed substantial decrements in digit recall following distraction by letter matching. To identify the nature of the interference effect, digit recall was scored according to a strict criterion where preservation of the serial order of the digits was required (order-based recall), and a lenient criterion where preservation of digit order was not required (order-free recall). While both groups showed a comparable decrement in order-based recall due to the interfering task, order-free recall virtually eliminated the decrement for the nondemented group whereas substantial interference was still observed in the demented group. These results suggest that letter matching interferes with digit recall in nondemented elderly primarily by disrupting order information. In the case of demented elderly, letter matching disrupts the preservation of item information as well.     

Dual-task performance in demented and nondemented elderly

The present study examined the ability of demented and nondemented elderly subjects to divide their attention between recalling digits and judging the similarity of pairs of letters. Both groups showed substantial decrements in digit recall following distraction by letter matching. To identify the nature of the interference effect, digit recall was scored according to a strict criterion where preservation of the serial order of the digits was required (order-based recall), and a lenient criterion where preservation of digit order was not required (order-free recall). While both groups showed a comparable decrement in order-based recall due to the interfering task, order-free recall virtually eliminated the decrement for the nondemented group whereas substantial interference was still observed in the demented group. These results suggest that letter matching interferes with digit recall in nondemented elderly primarily by disrupting order information. In the case of demented elderly, letter matching disrupts the preservation of item information as well.     

Longitudinal trajectory of Amyloid‐related hippocampal subfield atrophy in nondemented elderly

Hippocampal atrophy and abnormal β‐Amyloid (Aβ) deposition are established markers of Alzheimer's disease (AD). Nonetheless, longitudinal trajectory of Aβ‐associated hippocampal subfield atrophy prior to dementia remains unclear. We hypothesized that elevated Aβ correlated with longitudinal subfield atrophy selectively in no cognitive impairment (NCI), spreading to other subfields in mild cognitive impairment (MCI). We analyzed data from two independent longitudinal cohorts of nondemented elderly, including global PET‐Aβ in AD‐vulnerable cortical regions and longitudinal subfield volumes quantified with a novel auto‐segmentation method (FreeSurfer v.6.0). Moreover, we investigated associations of Aβ‐related progressive subfield atrophy with memory decline. Across both datasets, we found a converging pattern that higher Aβ correlated with faster CA1 volume decline in NCI. This pattern spread to other hippocampal subfields in MCI group, correlating with memory decline. Our results for the first time suggest a longitudinal focal‐to‐widespread trajectory of Aβ‐associated hippocampal subfield atrophy over disease progression in nondemented elderly.     

Invasions of personal space in demented and nondemented elderly persons

Personal space has been a research issue in both social psychology and nursing in the past 20 years. In the context of behavioral and psychological signs and symptoms in dementia (BPSSD), however, personal space and other basic paradigms of social psychology sparsely play a role. In order to assess personal space in demented (n = 10) and nondemented (n = 10) elderly participants, we replicated the original study addressing personal space by Felipe and Sommer (1966). The two groups differed in the overall number of participants showing a specific reaction, in the mean duration until specific reactions occurred, and in the percentage of participants within a group showing a specific reaction at a given point in time. The argument is being made that such findings might reflect situational as well as disease-specific changes in the perception of and reactions to invasions of personal space in demented patients. We suggest that further research in that field could bring about more information on the nature of dementia, and especially BPSSD. Implications for therapy and care of dementia patients are being discussed.     

HLA antigens in depressed, demented, and nondemented elderly

To identify HLA antigen associations with geriatric depression, the authors typed 36 elderly patients with major depression and, for comparison, 36 patients with Alzheimer-type dementia and 29 nondemented elderly controls. The frequency for antigen Aw32 was significantly higher in the group of patients with major depression (14%) than in the demented (0%) and control (3%) groups. The frequencies for antigens Aw32 (22%) and Bw51 (22%) were significantly higher in the subgroup of 23 patients with endogenous depression than in the demented (Aw32 = 0%; Bw51 = 11%) and the control (Aw32 = 3%; Bw51 = 0%) groups. Although these results were derived from a relatively small sample (n = 101) and become nonsignificant when corrected for multiple comparisons, they suggest that HLA antigen associations may be present for only certain depressive subtypes in geriatric depression.     

Patterns of cerebral hypoperfusion compared among demented and nondemented patients with stroke.

BACKGROUND AND PURPOSES: No reports are available that compare local cerebral perfusion among groups of patients suffering from multiple cerebral infarctions with and without cognitive impairments. The present study was designed to correlate changes in regional cerebral perfusion that may lead to dementia among patients with multiple cerebral infarctions by comparing measurements of local cerebral blood flow. METHODS: Local perfusion was measured using xenon-contrasted computed tomographic scanning among two groups of patients who had suffered from multiple cerebral infarctions: Group D (n = 12) were demented and had severe cognitive impairments, and group I (n = 11) were cognitively intact. Results were compared with similar measurements among neurologically and cognitively normal, age-matched volunteers (group N, n = 16). RESULTS: Mean local perfusion values were reduced among both groups with cerebral infarctions but to a more marked degree in group D (p less than 0.05). Perfusion of cerebral white matter was diffusely and severely reduced in group D (p less than 0.05) but was mildly reduced only in frontal and capsular white matter in group I (p less than 0.05). Perfusion of cerebral cortex was reduced in frontal (p less than 0.01) and temporal (p less than 0.01) regions among both groups but to a significantly greater degree in group D subjects (frontal, p less than 0.05; temporal, p less than 0.01), who also showed hypoperfusion of the occipital cortex (p less than 0.05), apparently because of underlying leukoaraiosis and cortical disconnections. Perfusion of the basal ganglia was reduced to the same degree among both groups of stroke patients (p less than 0.01). CONCLUSIONS: Leukoaraiosis with white matter hypoperfusion appears to be an important determinant for cognitive impairments among patients with multiple cerebral infarctions.     

Use of Prescription Medication by Individuals Who Died by Suicide in Northern Ireland

To understand medication use prior to suicide in relation to patterns, polypharmacy, and adherence. A total of 1,371 suicide cases were coded and latent class analysis used to identify combinations of medications prescribed prior to death. Two thirds had been prescribed medication with 30.7% prescribed 3 or more. Latent class analysis revealed three classes: Mixed medication use, primarily mental medication use, and baseline/low medication use. There are potentially high rates of medication non-adherence. Not only medication use but also non-adherence rates were high in this sample of individuals who died by suicide. Potential implications and areas for future research are discussed.     

Obesity and psychotropics

Weight gain is on the rise in the United States as is the diagnosis and treatment of mental disorders. These two phenomena are distinctly separate but tend to overlap in that most psychotropic agents approved for use in the United States are associated with the potential to induce weight gain. Metabolic disorders such as diabetes, hypercholesterolemia, and hypertension are also on the rise and often associated with weight gain and clearly associated with certain psychotropic medications. This article serves to provide a succinct review regarding the epidemiology, etiology, and treatment options for psychotropic-induced obesity.     

Regional quantitative study of formation process of neurofibrillary tangles in the hippocampus of non‐demented elderly brains: Comparison with late‐onset Alzheimer's disease brains

We quantitatively investigated the formation process of neurofibrillary tangles (NFT) in the hippocampus of 32 brains from non‐demented elderly persons using tau‐immunohistochemistry, compared with 13 brains from patients with late‐onset Alzheimer's disease (AD). The 32 non‐demented elderly brains were classified into 16 brains in group I and 16 brains in group II mainly based on the distribution of tau‐positive neurons in the hippocampus. Tau‐positive neurons were found predominantly in the CA2 in group I, while they were found predominantly in the subiculum～pre‐CA1 in group II. Most late‐onset AD brains showed a distribution of tau‐positive neurons similar to that in group II. In addition, the distribution pattern of tau‐positive neurons in the hippocampus was closely related to degeneration of the perforant pathway with the accumulation of tau. These findings suggest that NFT occur first in the CA2 and extend to the subiculum～pre‐CA1 in group I, while they occur first in the subiculum～pre‐CA1 and extend to the CA2 later in group II, and that the NFT occurring in the subiculum～pre‐CA1 are mainly related to degeneration of the perforating route and in the CA2 are related to the degeneration of the non‐perforating route.     

Medication use among Australian adults with intellectual disability in primary healthcare settings: A cross-sectional study

Abstract

Background There is concern about widespread medication use by people with intellectual disability (ID), especially psychotropic and anticonvulsant agents. However, there is sparse information on prescribing patterns in Australia.

Method This cross-sectional study was conducted between 2000 and 2002 among adults with ID who live in the community in Brisbane, Australia. Medication data were extracted from a health screening tool. Demographic and medical data were collected from telephone interviews and medical records.

Results Of 117 participants, 35% were prescribed psychotropic medications, most commonly antipsychotics, and 26% anticonvulsants. Complementary medications (vitamins, minerals, amino acids, fish oil, and herbal products) were used by 29% of participants. After adjusting for potentially confounding variables, psychotropic medication use was significantly associated with having a psychiatric illness (adjusted odds ratio = 4.6, 95% CI [1.0, 20.6]) and challenging behaviours (4.4, [1.1, 17.3]).

Conclusions People with ID use a broad range of medications. Psychotropic medications continue to be the most predominant agents prescribed for this population. Psychotropic medication use is positively associated with having a psychiatric illness and challenging behaviours.     

Predictors of mortality among demented elderly in primary care

OBJECTIVES: To evaluate a wide range of sociodemographic, neurological and clinical variables as to whether they predict mortality in a representative sample of demented elderly.DESIGN: A three-stage community survey was conducted, based on a total of 3721 elderly patients whose cognitive status was assessed by their general practitioners (stage I). A stratified random sample of patients underwent a standardized research interview, including cognitive testing and the assessment of mental status, physical illness, sensory impairment and motor disability (stage II). After a mean interval of 28 months, all patients were recontacted. For deceased patients a close reference person was interviewed and the exact date of death was recorded (stage III). The influence of the predictor variables on mortality was determined by using the Cox proportional hazards model.SUBJECTS: A stratified random sample of 117 patients in primary care (mean age 82 years) suffering from mild, moderate or severe dementia (Alzheimer type, vascular or mixed dementia).MATERIALS: Hierarchical Dementia Scale (HDS), a modified version of the Hamilton Depression Scale, other clinical rating scales and CAMDEX criteria for clinical diagnosis and a degree of severity of dementia.RESULTS: Fifty-three of the 117 demented patients had died during the follow-up interval. The mortality risk increased steeply with the degree of severity of dementia. By controlling for this variable, only age and motor disability contributed significantly to the prediction of mortality, whereas gender, social class, type of dementia, extrapyramidal signs and other clinical features showed no or only a weak effect on the outcome.CONCLUSION: The remaining life expectancy of the demented elderly depends primarily on the severity of the dementia, the patients' age and their general physical health. The influence of other clinical features which often have been hypothesized as indicators of specific subgroups of dementia was mainly due to their relationship to the disease severity.