More than the epidemiology of Alzheimer's disease: contributions of the Canadian Study of Health and Aging.

OBJECTIVE: To highlight contributions to knowledge made by the Canadian Study of Health and Aging (CSHA). METHOD: The CSHA began in 1991, with follow-ups in 1996 and 2001. It was national in scope, with 18 study centres and a coordinating centre. It included 10 263 participants; of these, 9008 were in the community, and 1255 were in institutions. In each phase, community participants were screened for cognitive impairment, and where appropriate, cognitive status was determined by a detailed clinical examination. Data on possible risk factors for dementia were collected at baseline. Data on caring for people with dementia were collected in each phase. RESULTS: The prevalence of dementia was established at 8% of those aged 65 years and over; incidence (new cases each year) was about 2%. Cognitive impairment not dementia (CIND) was more than twice as common as dementia. Factors affecting the risk of institutionalization, mortality, and the health of caregivers were examined. The costs of dementia were conservatively estimated at dollar 3.9 billion in 1991. Risk factors for Alzheimer's disease (AD) and vascular dementia are presented; it is noteworthy that physical activity appeared to protect against all forms of cognitive decline, particularly for women. Clinical contributions include the development of norms for several neuropsychological tests. Other topics include the health of those with CIND, predicting dementia, medication use, frailty and healthy aging, and urinary incontinence. CONCLUSION: The CSHA has contributed substantially to knowledge of the epidemiology of dementia, including AD, and to many other topics relevant to seniors' health.     

Elders with dementia living in the community with and without caregivers: an epidemiological study.

BACKGROUND: Previous studies of dementia and family caregiving have focused on individuals seeking diagnosis and treatment, and have rarely been conducted in representative community samples. Identifying demented individuals participating in a community survey, we determined (a) the factors associated with demented elderly living alone; (b) the factors associated with the demented elderly having caregivers; (c) the factors associated with increased levels of burden among caregivers of persons with dementia. POPULATION AND METHODS: During an epidemiological survey of a mostly rural U.S. community, the authors identified 116 noninstitutionalized elderly individuals with dementia. These individuals were classified into those living alone and those living with others; both groups were further classified into those with and without identifiable family caregivers. Characteristics of both caregivers and care recipients were examined. RESULTS: Approximately a third of the subjects with dementia lived alone, and only half of them had caregivers. The average age of the caregivers was 67.4 years, and 73% of them were women. Almost half of the caregivers were spouses, whereas almost a third were offspring, of the demented individuals. Over two thirds of caregivers lived with the subjects. Female caregivers were significantly younger than male caregivers. Multivariate analyses revealed that subjects with dementia who were living alone were independently and significantly more likely to be women and to have dementias of shorter duration, lesser severity, and lesser functional impairment than those living with others. Demented subjects with caregivers were more likely to have greater dementia severity, functional impairment, and cognitive impairment and more current cognitive and behavioral symptoms than those without caregivers. Demented subjects whose caregivers reported higher levels of burden were more likely to be women and to have greater dementia severity, functional impairment, and cognitive impairment and more current symptoms than those whose caregivers had no/minimal burden. CONCLUSIONS: These results draw attention to the problems of persons with dementia living alone, particularly those without caregivers. Our data also provide epidemiological confirmation of previous clinical/volunteer studies of dementia caregiving, as well as a preliminary assessment of need in the community at large. Living arrangements and caregiver issues should be taken into account when planning services for the elderly.     

Five-year follow-up of cognitive impairment with no dementia

CONTEXT: The importance of early identification of dementia has prompted numerous investigations of mild cognitive impairment and the preclinical stages of progressive degenerative disorders. To date, there is limited information from large-scale studies regarding outcomes of persons specifically identified with cognitive impairment but no dementia (CIND). OBJECTIVES: To investigate outcomes for persons with no cognitive impairment (NCI) or CIND, focusing on its etiologic subcategories, from the Canadian Study of Health and Aging (CSHA) and to examine the predictive validity of a set of core features thought to be early manifestations of subsequent dementia. DESIGN: Five-year, longitudinal follow-up of all persons without dementia examined during the first phase of the CSHA in 1991. SETTING: Community and institutional settings. PARTICIPANTS: Population-based sample of 883 persons with NCI and 801 persons with CIND at the first phase of the CSHA. At follow-up, 517 persons with NCI (59%) and 327 persons with CIND (41%) were alive and received clinical diagnoses. MAIN OUTCOME MEASURES: Mortality, institutionalization, and clinical diagnoses using the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria for dementia. RESULTS: Persons with CIND were more likely than those with NCI to die (49% vs 30%), to be admitted to facility care (29% vs 14%), or to receive diagnoses of dementia (47% vs 15%) at follow-up. Those subsequently diagnosed as having dementia were more likely to have had impaired memory, informant-reported change in memory, and functional impairment at baseline. CONCLUSIONS: Persons with CIND were more likely to have a negative outcome than persons with NCI during a 5-year interval. This was true across etiologic subcategories and suggests that the use of specific diagnostic criteria sets does not improve our identification of those who develop dementia compared with a broader, more inclusive approach. More factors contributed to the prediction of all forms of dementia than to AD, but the most accurate prediction was for those who remained dementia free.     

Cost-effectiveness of a collaborative dementia care management—Results of a cluster-randomized controlled trial

IntroductionThe purpose of this study was to determine the cost-effectiveness of collaborative dementia care management (DCM).MethodsThe cost-effectiveness analysis was based on the data of 444 patients of a cluster-randomized, controlled trial, conceptualized to evaluate a collaborative DCM that aimed to optimize treatment and care in dementia. Health-care resource use, costs, quality-adjusted life years (QALYs), and incremental cost per QALY gained were measured over a 24-month time horizon.ResultsDCM increased QALYs (+0.05) and decreased costs (?569€) due to a lower hospitalization and a delayed institutionalization (7 months) compared with usual care. The probability of DCM being cost-effective was 88% at willingness-to-pay thresholds of 40,000€ per QALY gained and higher in patients living alone compared to those not living alone (96% vs. 26%).DiscussionDCM is likely to be a cost-effective strategy in treating dementia and thus beneficial for public health-care payers and patients, especially for those living alone.     

Does aspirin affect outcome in vascular dementia? A retrospective case-notes analysis

BACKGROUND: Ischaemic vascular dementia shares risk factors with stroke. There is evidence that control of these risk factors may prevent or alter the course of vascular dementia. OBJECTIVE: To assess the effect of regular low-dose aspirin on outcomes for patients with vascular dementia. DESIGN: Retrospective analysis of hospital case-notes with further outcome information from telephone calls to general practitioners, social services and institutions. Comparison of outcomes for aspirin-treated and untreated patients. SETTING: One North London NHS Trust. PATIENTS: Seventy-eight patients with clinician's diagnosis of ischaemic vascular dementia, discharged from acute inpatient units between 1 January 1995 and 31 December 1997; 38 on aspirin. MAIN OUTCOME MEASURES: Survival times from dementia onset to institutionalization and death. RESULTS: Median survival time to institutionalization was 28 months and to death was 52 months. There was no overall difference between aspirin and non-aspirin groups for these outcomes. When data were stratified for social status, i.e. living alone or with carer when last at home, differences emerged for those living with carer. Aspirin was associated with a trend towards increased time to institutionalization (39 vs 22 months, p < 0.09) and a significant advantage in time to death (71 vs 27 months, p = 0.02). These effects were non-significant after statistical adjustment for confounding variables. CONCLUSIONS: The results support but do not prove a role for regular, low-dose aspirin in improving both life expectancy and survival at home for patients with vascular dementia. Compliance may be better in those living with a carer. Larger, prospective studies should be performed to confirm these findings. Cognitive and behavioural outcomes should also be studied.     

Dementia of acute onset in the Canadian Study of Health and Aging

BACKGROUND: Although most people with dementia experience an insidious onset of symptoms, in some cases onset can be acute. The importance of acute onset is unclear. Some reports suggest that it portends a worse course. METHODS: We performed a secondary analysis of the clinical examination cohort (n=2914) of the Canadian Study of Health and Aging (CSHA). We defined "acute onset of dementia" from the Cambridge Examination for Mental Disorders in the Elderly (CAMDEX) questionnaire, conducted with an informant. People with dementia of acute onset were compared to those with dementia of insidious onset for development of adverse outcomes of death and institutionalization over 5 years. RESULTS: Of the 1132 people who had dementia, 130 (11.5%) met criteria for acute onset. Compared with gradual-onset dementia patients, those with acute-onset dementia were more often men (42% vs. 30%, p < 0.05), resided in nursing homes (75% vs. 63%, p< 0.05), had vascular risk factors (72% vs. 47%, p < 0.05), and a Hachinski Ischemia Scale (HIS) score > or = 7 (64% vs. 19%, p < 0.05). More patients with dementia of acute onset than gradual onset were diagnosed with vascular dementia (55% vs. 13%; p < 0.05). Adjusted hazard ratios (HRs) for survival and institutionalization in the acute-onset group were 0.93 [95% confidence interval (CI) 0.7-1.2] and 0.76 (95% CI 0.4-1.3), respectively, compared with the gradual-onset group. CONCLUSIONS: People with acute-onset dementia had more vascular risk factors than those with gradual-onset dementia across all dementia diagnoses, and lower risks of institutionalization but worse survival. Routine inquiry about the onset of dementia might help to better clarify prognoses in patients with dementia.     

Effective Normative Samples For the Detection Of Cognitive Impairment in Older Adults

The inclusion of individuals with incipient dementia in normative data contaminates the distinction between normal and pathological aging. Conventional and Robust (excluding persons with incipient dementia) norms were created using data from the Canadian Study of Health and Aging (CSHA). Robust norms were not significantly better at distinguishing between normal and pathological aging. Norms reflecting the relationship between age and the prevalence of dementia revealed a probability of dementia of less than 35%. The results of the norming procedure serve to illustrate the validity of our current measures and methods for identifying cognitive impairment. CSHA Conventional norms are adequate for the identification of cognitive impairment.     

Effective normative samples for the detection of cognitive impairment in older adults

The inclusion of individuals with incipient dementia in normative data contaminates the distinction between normal and pathological aging. Conventional and Robust (excluding persons with incipient dementia) norms were created using data from the Canadian Study of Health and Aging (CSHA). Robust norms were not significantly better at distinguishing between normal and pathological aging. Norms reflecting the relationship between age and the prevalence of dementia revealed a probability of dementia of less than 35%. The results of the norming procedure serve to illustrate the validity of our current measures and methods for identifying cognitive impairment. CSHA Conventional norms are adequate for the identification of cognitive impairment.     

Placements in psychiatric institutions,nursing homes,and homes for the elderly by Belgian general practitioners

This research is an epidemiological study of long-term care facility admissions to various types of institutions (homes for the elderly, nursing homes, psychiatric institutions) during 1994 in Belgium. Data were obtained from a network of 143 general practitioners, which acts as a reliable surveillance system for health-related data. For every patient who was institutionalized, physicians were asked to record the following information: (1) type of institution in which the patient was placed; (2) medical conditions; (3) current living situation; (4) reason for institutionalization; (5) length of the waiting time for institutionalization, and (6) whether or not the patient was hospitalized prior to the institutionalization. The overall incidence for institutionalization among older patients was 1%. The most common medical conditions upon placement were functional impairments and dementia. Over half the patients lived alone just prior to the placement and family members made the majority of requests for placements. Compared to placements in other types of institutions, those to psychiatric facilities were more likely to be 'urgent' and waiting times for admission to these institutions were shorter. Over half of all placements were preceded by an admission to a medical hospital. Few placements (16%) were made with the consultation of home care services. Finally, in about two thirds of the cases, patients were cared for by their general practitioner while they were institutionalized.     

Prevalence of cognitive impairment and dementia as defined by neuropsychological test performance

The Canadian Study of Health and Aging (CSHA) provided a population-based estimate of the prevalence of dementia of 8% for those aged 65 and older. Other studies have produced both higher and lower prevalence estimates. Factors that may contribute to these differences include: the use of or the reliance on neuropsychological testing, the consideration of functional impairment as a criterion for dementia and the inclusion of the category of cognitive impairment without dementia in the diagnostic classification. We examined the impact of these methodological factors by reanalyzing the CSHA database for those individuals who completed neuropsychological testing. If the diagnosis of dementia required only impaired neuropsychological test performance, there was an increased prevalence of dementia relative to the clinical consensus diagnosis, but including the requirement of functional impairment for dementia reduced this discrepancy. The findings illustrate the need for clear operationalization of diagnostic criteria for cognitive impairment and dementia in neuroepidemiological studies.     

Institutionalization risk amongst people with dementia supported by family carers in a Scottish city

We studied 114 community-resident demented older people living at home with the support of a family carer and a matched sample of 114 non-demented older people to determine the factors predictive of institutionalization. We interviewed elders and carers for presence and severity of dementia, characteristics of elder and carer, service use, and carers' perceptions of needs and attitudes to care. Subjects were followed up over a 2-year period. Eleven demented and 10 non-demented elders were lost to follow-up. Forty-nine of 103 demented and 7 of 104 non-demented elders were institutionalized. Demented elders were 8.21 times more likely to be institutionalized than non-demented elders, adjusting for age and sex (95% CI 3.69-18.23). Using Cox's Proportional Hazards Model, factors which predicted institutionalization amongst demented elders were: Mini Mental State Examination Score (RR 0.87, 95% CI 0.80-0.96), carers' perceived problems in relation to the elders' physical disabilities (need for 1-3 hours per week vs no need, RR 6.10, 95% CI 2.34-15.89), behavioural problem score (7-13 vs 6, RR 5.67, 95% CI 1.47-21.88) and carers' willingness to continue caring (willing vs totally willing RR 4.46, 95% CI 1.41-14.10). Our study confirms the high risk of institutionalization amongst demented older people. Early institutionalization of demented elders can be predicted and should be planned for, to help elders and carers cope with the process of adjustment. Where carers are totally committed to continuing care, intensive community support may be required for problems associated with advanced dementia.     

Five-year outcomes for dementia defined solely by neuropsychological test performance

Cognitive impairment that does not meet criteria for dementia is common and progresses to dementia at a high rate. It is not clear how best to define this type of cognitive impairment. We assessed the predictive validity of different case definitions for cognitive impairment and dementia by comparing rates of adverse outcomes for individuals who did not meet dementia criteria but had neuropsychological test results indicating dementia (NPDementia), those who had traditional dementia diagnoses (mild and moderate-severe severity), those who had other cognitive impairment but no dementia (CIND), and those with no cognitive impairment (NCI). Our sample comprised 1,659 participants who had completed a neuropsychological assessment in the Canadian Study of Health and Aging, a prospective, cohort study of 10,263 randomly selected persons aged 65 years or older. Outcomes were determined after 5 years. Institutionalization and death rates for the NPDementia and CIND groups were higher than for the NCI group. Both groups had lower institutionalization rates than the two Dementia groups and lower death rates than the Moderate-Severe Dementia group. Rates of progression to dementia were increased in NPDementia and CIND groups, relative to the NCI group, and the NPDementia group was less likely than the CIND group to revert to a diagnosis of NCI at the 5-year follow-up. Thus, individuals with NPDementia and CIND have substantially worse outcomes over 5 years than those with NCI. The case definition of NPDementia identified individuals with cognitive impairment that is unlikely to resolve and likely to progress to dementia.     

Normal aging and dementia disorders--coping and crisis in the family

At present we have limited possibilities to treat dementia disorders. One way to intervene in the progress is to support the family. In this investigation the situation of the family and the primary caregivers to patients with dementia disorders are studied. One group consists of 171 patients admitted to a geropsychiatric unit. Relatives to these patients were interviewed. A subgroup of these patients were formed consisting of 28 patients with Alzheimer's disease and senile dementia of Alzheimer type. The patients in this group were rated with a geriatric scale for measuring dementia. In another group of 28 long-stay patients on a geriatric ward the level of dementia and the family situation was studied. As a control group 26 individuals from a county in Sweden was chosen, all of them 85 years of age or older. They were considered the most healthy individuals in the area in this age group. The need of support for these individuals was studied. The results indicate that individuals in high age, although considered healthy, need much support. All the families to patients with dementia disorders need support more or less. Either group therapy or individual psychotherapy can be given. Adequate formal help from the society and psychological support to the primary caregivers probably delay institutionalization.     

Support networks and dementia

Based on data from a sample of 4500+ people aged 65+ living in the community (ie not in residential care) in Liverpool, this article presents data on the availability of kin and levels of contact with family, friends neighbours and community groups, and compares the distribution of support network types of those identified as cases of dementia with non-cases. It is shown that dementia sufferers are more likely to live with others and to have more contact with family members and less contact with friends, neighbours and community groups than non-sufferers. It is also shown that the distribution of network type is distinctively different for cases and non-cases and it is suggested that this reflects the greater ability of some types of network to support continued community residence in the face of the onset of dementia.     

Dementia in subjects aged 75 years or over within the PAQUID cohort: prevalence and burden by severity

BACKGROUND/AIMS: To analyze the prevalence of dementia by severity and to describe the sociodemographic characteristics of people with dementia in the community, as well as the consequences of this disease in terms of disability and institutionalization. METHODS: This study was based on the PAQUID community-based cohort study of 1,461 subjects aged 75 years or over. Severity of dementia was assessed using the Mini-Mental State Examination (MMSE). RESULTS: The prevalence of dementia was estimated to be 17.8%, with about 43% at a moderately severe or more severe stage of the disease (MMSE 相似文献   

Mild cognitive impairment and everyday functioning in older adults

The relations between mild cognitive impairment without dementia (MCI/CIND) and everyday functional abilities were examined using data from the Canadian Study of Health and Aging (CSHA). Individuals were identified with MCI/CIND if both caregiver report and clinician judgment agreed on the presence of cognitive impairment in the absence of dementia. Cross-sectional and longitudinal comparisons indicated that individuals with MCI/CIND demonstrated a broad range of impairment in instrumental activities of daily living (IADL) compared to individuals with no cognitive impairment (NCI). In cross-sectional analyses, neuropsychological measures of memory and psychomotor speed were significantly related to impairment in eight areas of functioning. In addition, poorer memory performance was significantly predictive of future impairment in money management.     

Mild cognitive impairment and everyday functioning in older adults

The relations between mild cognitive impairment without dementia (MCI/CIND) and everyday functional abilities were examined using data from the Canadian Study of Health and Aging (CSHA). Individuals were identified with MCI/CIND if both caregiver report and clinician judgment agreed on the presence of cognitive impairment in the absence of dementia. Cross-sectional and longitudinal comparisons indicated that individuals with MCI/CIND demonstrated a broad range of impairment in instrumental activites of daily living (IADL) compared to individuals with no cognitive impairment (NCI). In cross-sectional analyses, neuropsychological measures of memory and psychomotor speed were significantly related to impairment in eight areas of functioning. In addition, poorer memory performance was significantly predictive of future impairment in money management.     

Out of sight out of mind? Support and information given to distant and near relatives of those with dementia

OBJECTIVES: Increasing attention has been paid to the needs of family members caring for a person with dementia but little has been written about the impact on the wider family. This paper was intended to see whether the need for information would stretch to those relatives living far from the patient. METHOD: A case-control study comparing two sets of relatives of community-dwelling probands in contact with secondary services and having a clinical diagnosis of dementia: one set of relatives living less than an hour away and another set living further away.The reported need for and source of information obtained by relatives was questioned using a specially designed questionnaire. Mini Mental State Examination (MMSE) and Clinical Dementia Ratings Scale were used with probands. RESULTS: Relatives living distantly from the person with dementia reported similar rates of subjective distress but were more often dissatisfied with information received. Distant relatives were also less likely to access information from books or lay societies. CONCLUSION: The impact of having a relative with dementia does not lessen with distance. The wider family need support and information as well as 'primary carers'. If the whole family is to be supported in their caring role, then clinicians and the lay societies need to widen their supportive net.     

A follow-up study of psychogeriatric day hospital patients with dementia

One hundred and fifty-five patients suffering from dementia who attended a psychogeriatric day hospital in 1985 were reviewed three years later. This review was performed to determine what proportion of discharges from the unit were unplanned or unforeseen and to look for any patterns in the care experienced by different groups of patients. The discharges were classified as planned or unplanned and by the living circumstances to which discharged. The outcome of patients surviving at follow-up was also classified by living circumstances. Forty-five per cent of discharges were unplanned. Significant differences were noted when comparing patients who had been living alone and those living with their spouses. The former, if institutionalized, were more likely to be admitted to a residential or nursing home whereas the latter were more likely to have been admitted to hospital. More of those living alone were alive at follow-up. The findings of this study support the view that day hospital provision has little effect on the eventual need for long-term care and that this need is related to the attitude and stamina of careers.     

Psychosocial predictors of dementia caregiver desire to institutionalize: caregiver, care recipient, and family relationship factors

Several factors influence dementia caregiver desire to institutionalize; however, little is known about differences in caregivers who desire institutionalization versus those who do not. The current study compares predictors of desire to institutionalize in dementia caregivers. Seventy-two caregivers completed the Desire to Institutionalize Scale (DIS) and several psychosocial measures, including burden, dementia knowledge, self-efficacy, depression, health, care recipient daily functioning and memory/behavior problems, family functioning, and social support. Based on DIS responses, caregivers were divided into No DI versus DI groups. DI caregivers had significantly higher burden, greater dementia knowledge, more family dysfunction, and decreased social support compared with No DI caregivers. Findings emphasize the importance of caregiver and family relationship variables in DIS, suggesting potentially modifiable targets for caregiver interventions. Dementia knowledge was associated with higher DIS, suggesting that educational programs alone may not be helpful to delay institutionalization.