Community-dwelling persons with dementia: What do they need? What do they demand? What do they do? A systematic review on the subjective experiences of persons with dementia

Objectives: Including the perspectives of persons with dementia (PwD) is essential in order to organize care structures for them. With this systematic review, we set out to screen the existing scientific evidence on self-expressions of community-dwelling individuals with dementia in order to provide a research base for developing an intervention for persons in early stages of the disease. The leading research questions for this review are: What needs do PwD living at home express? What are their subjective demands? What do they do to cope with their situation?

Methods: We performed a systematic literature review of review publications on subjective experiences of PwD. The publications were analysed using MAXQDA 10 to perform a thematic analysis.

Results: We identified 41 relevant reviews, of which 6 met our inclusion criteria. PwD experience the whole range of human emotions. Their needs and demands do not differ significantly from those of other groups of patients with chronic conditions. Coming to terms with the disease and maintaining normality appeared to be major themes. With regard to expectations from the side of professional health care, the need for accompanying, continuous support and counselling appeared to be central. Furthermore, disclosure of diagnosis represents a critical stage for PwD, but our findings indicated that they prefer to be included in this process.

Conclusions: PwD are well able to express their needs. They should be included in research since they can provide valuable findings. Furthermore, those findings should be implemented in applied dementia care.     

Does serum prolactin indicate the presence of seizure in the emergency department patient?

Abstract. Study objective: We sought to evaluate whether there was a correlation between elevated serum prolactin in patients presenting with the question of seizure. Methods: A Convenience sample of 200 consecutive patients were chosen who had a serum prolactin measurement in the setting of seizure activity. Results: The prolactin level was within a range of 3.90–294.00 mg/dl with an upper limit of normal being 29.9 mg/dl. Patients were ultimately diagnosed with seizure in 54.5% (109 of 200) with an abnormal prolactine in 31.0% (62 of 200). The sensitivity of this serum prolactin was 42%, the specificity was 82%, positive predictive value (PPV) of 74%, and negative predictive value (NPV) of 54%. There was an overall accuracy of 60% in the diagnosis of seizure, with a likelihood ratio of 2.4 (95% Confidence Interval [CI], 1.5–3.9). Conclusion: The measurement of serum prolactin is helpful as a confirmatory test, but not as screening test in the emergency department setting.     

Transient patterns of cortical lamination during prenatal life: do they have implications for treatment?

Transient laminae containing circuitry elements (synapses, postsynaptic neurons and presynaptic axons) appear in the cerebral wall from the eighth postconceptional week (PCW) and disappear with the resolution of the subplate zone after the sixth postnatal month. The first endogeneous synaptic circuitry develops in two laminae, above and below the cortical plate. Mid- and late fetal period (15–23 PCW) shows lamination pattern with a thick subplate zone containing GABAergic, glutamatergic and peptidergic neurons, synapses and thalamocortical afferents which are waiting and accumulating in the superficial subplate zone between 21 and 23 PCW and these mark regional boundaries. In preterm infants, some thalamocortical fibers relocate to the cortical plate in visual, somatosensory, auditory and associative cortices, forming a framework for sensory-driven connectivity, while other remain engaged in the endogeneous subplate zone circuitry. Corticocortical pathways continue to grow. In the neonatal period, there is a major reorganization of callosal projections and development of short corticocortical connections, dendritic spines and synapses. In conclusion, transient neuronal circuitry underlies transient functions during the fetal, perinatal and early postnatal life and determines developmental plasticity of the cerebral cortex and moderates effects of lesion of the developing brain.     

Pregnancy registries: What do they mean to clinical practice?

Multiple surveillance pregnancy registries have been established in order to better understand the effects of antiepileptic drugs (AEDs) on pregnancy. These registries are either hospital based, population based, or pharmaceutical based and are primarily focused on the potential teratogenicity of AEDs. The main outcome variable for most of these registries is the risk of major congenital malformations. Registries also gather data on other aspects of pregnancy, including seizure control. The methodology of the registries varies. They have different populations, ascertainment strategies, follow-up, and reporting criteria. These differences limit the ability to allow direct comparisons. Overall, the registry data suggest that the overwhelming majority of women with epilepsy treated with AEDs will have normal, healthy babies. A second consistent finding is that valproate, particularly at higher doses, is associated with a higher risk of major congenital malformations than other AEDs.     

The benzodiazepine site of the GABAA receptor: an old target with new potential?

The gamma-aminobutyric acid-A (GABA(A)) receptors is the target for the most widely prescribed sleep medicines. It is a ligand-gated ion channel, activated by the amino acid neurotransmitter GABA, which normally results in hyperpolarization of neurons leading to reduced action potential firing, and thereby a reduction in neuronal activity. It has a rich pharmacology with a number of separate modulator binding sites. The best studied of these is the benzodiazepine site. Modulation of GABA(A) receptor activity by benzodiazepines produces sedative, hypnotic, anxiolytic and anticonvulsant activities. Short half-life benzodiazepines such as triazolam have been particularly useful in treating insomnia, but concerns have been raised regarding tolerance potential and dependence liability of classical benzodiazepines, which has led to reduced prescribing of these agents. In recent years, the treatment of sleep disorders has moved towards the use of non-benzodiazepine sedative hypnotics. These agents act at the same site on the GABA(A) receptor, but feature less of the problems associated with classical benzodiazepines. Recent progress in our understanding of the diversity and pharmacology of GABA(A) receptor subtypes has provided a rational explanation for the efficacy of these compounds. Findings from preclinical studies reveal promising avenues for the design of better therapeutics in the near future.     

Polymorphisms of platelet adhesive receptors: do they play a role in primary intracerebral hemorrhage?

BACKGROUND: Several reports suggested that polymorphisms affecting the structure or level of the main adhesive platelet glycoproteins (GPs) could behave as genetic risk factors for arterial thrombotic disorders. However, very few reports analyzed the significance of these polymorphisms in bleeding disorders. Interestingly, one study suggested a role of the 807 C/T polymorphism of the collagen receptor GP Ia in the severity of the bleeding manifestations in von Willebrand disease. The aim of this study was to evaluate the role of frequent polymorphisms affecting platelet GPs in primary intracerebral hemorrhage (PIH), the third most frequent cause of cerebrovascular disorder. METHODS: We evaluated the role of four putative prothrombotic polymorphisms: GP Ia [807 C/T, and human platelet alloantigen system 5 (HPA-5)], GP Ibalpha (variable number of tandem repeats), and GP IIIa (HPA-1) in 141 Caucasian patients diagnosed of PIH, 141 race-, age-, sex- and risk factor-matched controls, and 446 subjects from the general population. RESULTS: The frequency of genotypes and alleles were similar between patients and controls. CONCLUSIONS: Our results suggest that these polymorphisms play a minor role in PIH.     

Precursors of neurons,neuroglia, and ependymal cells in the CNS: what are they? Where are they from? How do they get where they are going?

Neurons, neuroglia (astrocytes and oligodendrocytes), and ependymal cells are three distinct categories of neural cells in the central nervous system. In the mature brain and spinal cord, the classical histological criteria define these cells by their microscopic structure very well. During development, the precursors for all of these cells reside within the epithelium of the neural plate and its successor, the neural tube. These precursor cells are the undifferentiated, primitive neuroepithelium of the classical literature. As the cerebral vesicles enlarge and their walls thicken, the primitive neuroepithelial cells elongate, maintaining a radial orientation until they migrate. Although many, but not all, of these cells span the extent of the ventricular wall, they are the precursors of neurons, neuroglia, and ependymal cells. Thus, it is useful to retain their classical designation as primitive neuroepithelial cells and to treat them as neural precursor cells. Neural precursor cells are neither neuroglia nor neurons. It is not appropriate to call them radial glial cells anymore than it is to call them radial neuronal cells. The term "radial glia" has long been used to describe the mature, elongated astrocytes, represented by Bergmann cells in the cerebellum and Müller cells in the retina. Inevitably, during development, transitional forms between neural precursor cells and the neurons, neuroglia, and ependymal cells will occur. Such transitional cells are known as neuroblasts, glioblasts, or ependymoblasts, even though they may be postmitotic. Alternative terms are "immature neurons," "immature neuroglia," and "immature ependymal cells." The migration of many neural precursor cells is accomplished by translocation rather than free cellular locomotion. There is both direct and indirect evidence to document the translocation of the nuclear/perikaryal/somal complex through the leading process of primitive neuroepithelial cells. This is conspicuous in the neocortex, where the discrete radial arrangement of pyramidal cells may result from translocation of neuroblasts, while their leading processes still contact the pial surface. Migration by translocation occurs throughout the CNS. GLIA 43:6-18, 2003.     

Elevated serum concentrations of troponin T in acute stroke: What do they mean?

Elevations in serum troponin T in acute stroke have been suggested as an early marker of a poor outcome. A prospective, case-control study was undertaken to define characteristics associated with elevations in troponin T concentrations. Consecutive admissions to the Royal Adelaide stroke unit were assessed. Stroke outcome was determined using the modified Rankin scale. Elevated serum troponin T was seen in 12/109 (11%) of patients with stroke and was associated with more severe stroke, larger lesion volume and a worse outcome. However, as a prognostic indicator, elevations in troponin T had lower sensitivity for predicting death or dependence at discharge than the National Institute of Health Stroke Scale. Troponin T levels are elevated in a significant proportion of patients with acute stroke, principally those with large infarcts affecting the territory supplied by the middle cerebral artery but their value as a prognostic indicator remains uncertain.     

Adult-onset leukodystrophies from respiratory chain disorders: do they exist?

Respiratory chain disorders (RCDs) have been included in the differential diagnosis of adult-onset leukodystrophies. Here, we first report a 32-year-old female with an atypical, adult-onset, non-syndromic RCD due to a mitochondrial DNA deletion and manifesting as complicated ataxia. A ‘leukodystrophic’ pattern was found on brain MRI, but it was neither isolated nor predominant because of the presence of overt basal ganglia and infratentorial lesions, which led us to the proper diagnosis. Subsequently, we evaluated our series of patients with RCDs in order to verify whether a ‘leukodystrophic’ pattern with little or no involvement of deep grey structures and brainstem may be found in adult-onset RCDs, as reported in children. Among 52 patients with adult-onset RCDs, no case with a ‘leukodystrophic’ pattern was found, apart from three cases with a classical phenotype of mitochondrial neurogastrointestinal encephalopathy. In addition, no case of RCDs was found among six cases of adult-onset leukodystrophy of unknown origin and at least one feature suggestive of mitochondrial disease. The review of the literature was in agreement with these findings. Thus, we provide evidence that, unlike in children, RCDs should not be included in the differential diagnosis of adult-onset leukodystrophies, except when there are additional MRI findings or clinical features which unequivocally point towards a mitochondrial disorder.     

The Cognition and Emotional Well-being indices of the Parkinson's disease questionnaire-39: What do they really measure?

IntroductionThe Parkinson's disease questionnaire-39 (PDQ-39) is a common measure of health related quality of life (HRQoL) that is widely used with Parkinson disease (PD) patients. Previous evidence suggests that the PDQ-39 reflects at least 8 dimensions (i.e., Emotion, Cognitions, Mobility, etc). To date, little research has examined the external/convergent validity of the Cognitions and Emotional Well-being domains of the PDQ-39.MethodsA convenience sample of 303 PD patients underwent a comprehensive multi-domain neuropsychological evaluation, including tests of execution function, episodic verbal memory, processing speed, language and working memory, as well as completing measures of depression, apathy, state and trait anxiety and HRQoL (PDQ-39). Hierarchical regressions were conducted in order to examine the relationship between scores on neuropsychological tests and the Cognitions index, as well as mood measures and the Emotional Well-being index of the PDQ-39.ResultsNeuropsychological test performance did not account for a significant amount of variance in the PDQ-39 Cognitions index scores. Instead, it was depression that significantly contributed to the Cognitions index, above and beyond neuropsychological performance. The PDQ-39 Emotional Well-being index was also related to mood measures, primarily depression and trait anxiety.ConclusionsThe PDQ-39 Cognition index may be more related to mood functioning, as opposed to cognitive functioning, and should not be considered a “proxy” for cognitive functioning. Future studies are needed to better explain the construct of this index.     

Quality of life in dementia: do professional caregivers focus on the significant domains?

The domains of quality of life that are considered important by people with dementia and professional caregivers are not in agreement. This explorative study addresses the question, "To what degree do professional caregivers, in their daily working routine, focus on the quality-of-life domains that people with dementia consider essential?" Study participants were nursing assistants who work in 24-hour nursing home care and professionals who offer daytime activities. Three hundred and seventy-four caregivers working on 29 units and 3 day care facilities of 13 nursing homes and in 12 meeting centers filled out a questionnaire. The caregivers reported to focus at least to some degree on most domains considered important by people with dementia. However, relatively little attention was paid to "financial situation" and "being useful/giving meaning to life." Professionals who offer daytime activities focused more than 24-hour care staff on "attachment," "enjoyment of activities," "sense of aesthetics," and "being useful/giving meaning to life."     

Injections of depot antipsychotic medications in patients suffering from schizophrenia: do they hurt?

INTRODUCTION: Long-acting depot injections of antipsychotic medications are an important way to monitor treatment noncompliance in patients suffering from schizophrenia. Pain and discomfort at the injection site may result in patients' refusal of depot injections. The present study is a pilot study that attempts a systematic characterization of injection site pain. METHOD: Thirty-four consecutive outpatients suffering from DSM-IV-defined schizophrenia or schizoaffective disorder and treated with depot antipsychotic medications were evaluated. The pain they suffered from the injections was quantified using a visual analog scale. This evaluation was made 5 minutes before the injection, 5 minutes after. 2 days after, 10 days after, and before the next injection. Patients were also administered a modified version of the Rating of Medication Influences scale that included a specific question on the possible relationship between injection-associated pain and future compliance to depot treatment. RESULTS: The depot injections cause pain, which is maximal immediately after the injection, declines substantially 2 days after, and disappears by the tenth day after the injection. A correlation exists between reported injection site pain and the effect it has on patients' attitude toward the depot injection as reported by the patients. Zuclopenthixol depot injection is more painful than other depot medications. CONCLUSION: Depot injections are painful. The pain they inflict has a typical course, and medication type is among the factors that influence this pain. This pain might have an effect on patients' attitude toward depot injections and thus is of importance in the management of patients suffering from schizophrenia.     

Effectiveness of benzodiazepines: do they work or not?

The benzodiazepines have been extensively prescribed for decades for vague indications such as anxiety, sleeplessness and muscle tension. Despite increasing knowledge of their adverse effects, such as sedation, psychomotor and cognitive impairment, and dependence on long-term use, and the recent advent of better alternatives, their use continues largely unabated. The paper under review assesses the sparse high-quality data related to efficacy (denoted by the dropout rate for failure to respond), effectiveness (dropout rate for any reason) and dropout for adverse effects. The conclusion is that efficacy was significantly higher for the drugs as compared with placebo; by contrast, no convincing evidence was found of any short-term effectiveness: and adverse effects were 1.5-times more frequent in the drug-treated patients. Various reasons for these results are discussed. I point out the changes in diagnostic criteria over the years and the lack of accepted methods of assessing estimates of effectiveness in clinical practice. Excessive prescribing of these controversial drugs is likely to continue.     

Animal models of depression and anxiety: What do they tell us about human condition?

While modern neurobiology methods are necessary they are not sufficient to elucidate etiology and pathophysiology of affective disorders and develop new treatments. Achievement of these goals is contingent on applying cutting edge methods on appropriate disease models. In this review, the authors present four rodent models with good face-, construct-, and predictive-validity: the Flinders Sensitive rat line (FSL); the genetically “anxious” High Anxiety-like Behavior (HAB) line; the serotonin transporter knockout 5-HTT^−/− rat and mouse lines; and the post-traumatic stress disorder (PTSD) model induced by exposure to predator scent, that they have employed to investigate the nature of depression and anxiety.     

What do we know about the mechanism of action of the placebo?

The placebo is a substance or a procedure capable to induce a subjective or objective healing effect, but which efficacy or mechanism of action could not be demonstrated by the conventional scientific procedures. The main objective of this review is to synthesize the theories about the way the placebo acts. Conditioning, expectancy and desire theories, as well as the possible symbolic level in which placebo acts are reviewed. Some recent investigations showed that nerobiological responses elicited by placebo administration mimic those induced by it corresponding active drug. Finally, following evidences from development research, we suggest, that early expierences provide individuals with a "correction program of physiological functions" which could be eventually activated by contextual clues, as placebo.     

The GABAA receptor: a novel target for treatment of fragile X?

GABA(A) receptors are the major inhibitory neurotransmitter receptors in the mammalian brain, implicated in anxiety, depression, epilepsy, insomnia, and learning and memory. Here, we present several lines of evidence for involvement of the GABAergic system, and in particular the GABA(A) receptor-mediated function, in fragile X syndrome, the most common form of inherited mental retardation. We argue that an altered expression of the GABA(A) receptor has neurophysiologic and functional consequences that might relate to the behavioural and neurological phenotype associated with fragile X syndrome. Interestingly, some neuropsychiatric disorders, such as anxiety, epilepsy and sleep disorders, are effectively treated with therapeutic agents that act on the GABA(A) receptor. Therefore, the GABA(A) receptor might be a novel therapeutic target for fragile X syndrome.