There are a number of ways in which a clinical diagnosis of dementia of the Alzheimer type can be made – the application of clinical criteria is the commonest but ancillary techniques such as neuroima

Clinical Diagnosis of Alzheimer's Disease

Michel Foucault takes the reader on a serendipitous journey in tracing the history of madness from the 16th to the 18th centuries. Utilizing original documents, the author recreates the mood, the place, and the proper perspective in the history of madness. Madness or folly is viewed as part of the human condition and to be examined and illuminated through one of its many facets. At the end of the Middle Ages madness was seen either as a tragic or comic phenomenon. The Renaissance, with Erasmus' Praise of Folly , demonstrated how imagination and its derivatives were to thinkers of that day. The French Revolution introduced the so-called medical approach. Madness is a ubiquitous phenomenon that has common roots not only in medicine but in poetry and tragedy. Shakespeare brilliantly describes psychological phenomena with even greater clarity than Tuke or Wills. The author weaves a fascinating history showing the changing pattern of

Madness and Civilization: A History of Insanity in the Age of Reason.

This meta-analysis integrates results from 229 studies on gender differences in caregiver psychological and physical health, caregiving stressors, and social resources. Contrary to common perceptions, gender differences in caregiving variables were small to very small. Women had higher levels of burden and depression, and lower levels of subjective well-being and physical health. They reported that their care recipient had more behavioral problems; they provided more caregiving hours, helped with more caregiving tasks, and assisted with more personal care. Women and men did not differ in the use of informal and formal support. Statistically controlling for gender differences in stressors and resources reduced the size of gender differences in depression and physical health to levels that have been observed in noncaregiving samples. The results support stress-and-coping theories on gender differences in caregiving.

Gender Differences in Caregiver Stressors, Social Resources, and Health: An Updated Meta-Analysis

Objective To acquire an understanding of the societal costs of dementia and how they affect families, health and social care services, and governments to improve the lives of people with dementia and their caregivers. Methods The basic design of this study was a societal, prevalence-based, gross cost-of-illness study in which costs were aggregated to World Health Organization regions and World Bank income groupings. Results The total estimated worldwide costs of dementia were US$604 billion in 2010. About 70% of the costs occurred in western Europe and North America. In such high-income regions, costs of informal care and the direct costs of social care contribute similar proportions of total costs, whereas the direct medical costs were much lower. In low- and middle-income countries, informal care accounts for the majority of total costs; direct social care costs are negligible. Conclusions Worldwide costs of dementia are enormous and distributed inequitably. There is considerable potential for cost increases in coming years as the diagnosis and treatment gap is reduced. There is also likely to be a trend in low- and middle-income countries for social care costs to shift from the informal to the formal sector, with important implications for future aggregated costs and the financing of long-term care. Only by investing now in research and the development of cost-effective approaches to early diagnosis and care can future societal costs be anticipated and managed.

The worldwide economic impact of dementia 2010

Aims: The aims of this study are to (1) explore the determinants of quality of life (QoL) in nursing home residents with young-onset dementia (YOD), (2) investigate whether there are differences between dementia subtypes (Alzheimer dementia, vascular/mixed dementia, frontotemporal dementia, other) regarding these determinants, and (3) compare QoL profiles of YOD nursing home residents across dementia subtypes. Methods: This cross-sectional study included 207 nursing home residents. Multilevel modeling was used to determine the relationships between QoL and neuropsychiatric symptoms (NPS), dementia severity, psychotropic drug use (PDU), dementia subtype, age, and gender. Additional multilevel models were used to compare aspects of QoL between dementia subtypes. Results: Residents' QoL was negatively associated with advanced dementia, PDU, and NPS. In general, the relationships between the determinants and QoL were similar across the dementia subtypes. Aspects of QoL differed by dementia subtype. Residents with frontotemporal dementia showed less negative emotions, accepted more help and experienced better quality of relationships with professional caregivers, had a more positive self-image, felt more comfortable in the nursing home environment, and experienced lower quality of social relationships. Conclusions: Considering the high rates of NPS and PDU in YOD residents and their negative associations with QoL, we recommend emphasizing services to manage and reduce NPS and PDU in nursing home residents with YOD. Furthermore, our findings suggest accounting for differences in aspects of QoL by dementia subtype to address specific needs and thereby improve QoL.

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The Determinants of Quality of Life of Nursing Home Residents with Young-Onset Dementia and the Differences between Dementia Subtypes.

BACKGROUND: Alzheimer's disease and related syndromes have heavy social and human consequences for the patient and his family. Beyond the neuropsychiatric effects of specific therapies for dementia, one of today's challenges is the quality of life for both patients and their informal caregivers. OBJECTIVES: This survey tends to determine parameters influencing caregivers' quality of life, and its possible link with patients' quality of life. METHODS: A scale measuring caregivers' quality of life, developed from data from previous PIXEL studies was used. It is a questionnaire composed of 20 items. The scale was related to the socio-demographic data of both patients and their main caregivers, to the ADRQL scale (Alzheimer Disease Related Quality Life) of Rabins for the QoL of dementia patients, to the patients medical and therapeutic data, specially a neuropsychological inventory: Folstein's cognition test, Cornell's depression scale, the fast battery of frontal assessment, Katz's dependence index, Cummings' neuropsychiatric inventory for behavioral and psychological symptoms of dementia and to a physician evaluation of caregiver's depression. RESULTS: One hundred patients diagnosed with dementia who live at home with their principal caregivers were recruited for this survey. Patients were 80.2 +/- 6.8 years old and caregivers were 65.7 +/- 12.8 years old. The caregivers' quality of life was correlated to the quality of life of the patients they cared for, the importance of behavioral disorders, and the duration of dementia evolution. Women caregivers had a worse quality of life and were more depressive than men. DISCUSSION: Caregivers' and patients' quality of life are related and both share a community of distress.

Dementia patients caregivers quality of life: the PIXEL study.

Background

The aim of this study is to look at the correlation between the presence of apathy measured by Marin's scale and family complaints related to withdrawal and the loss of motivation, or depression. The multicentre study was performed on 58 non-demented elderly people, 132 outpatients with Alzheimer's-type dementia, as well as their main caregiver.



Methods

After agreement of the patients and the family, the patients were assessed using different scales: Cornell's for depression, Marin's for apathy, MMS for cognitive disorders, and IRG for dependence. At the same time, two self-administered questionnaires were given to the patients' families: one concerning a list of complaints scored from 1 to 4 relating to various disorders and the other addressing the boundary ambiguities translated from Boss' questionnaire. The 58 non-demented people were 81.20 years old±13.75. One hundred and thirty-two demented patients were included: 39 men and 93 women. The mean age was 79.47 years±9.03.



Results

The first family complaint relates to the loss of motivation (65%). Apathy and depression occur more frequently in dementia, in particular when the MMS is degraded. Depression and apathy attracted a high complaint score. In our study the score of boundary ambiguity is higher among patients with a weak cognitive status. A high level of ambiguity is accompanied by a high score of family complaints. When the family complaint concerning the loss of motivation is present, apathy is significantly more common. Family complaints about withdrawal and loss of motivation are frequently present, and are congruent with the actual presence of apathy in the patient. It bears witness to the distress felt by families faced with the loss of ability noted in the demented person. The family's difficulties are increased by the patient's depression. Copyright © 2001 John Wiley & Sons, Ltd.

Family, Alzheimer's disease and negative symptoms.

Context

Study of the problems and requirements of the main caregiver providing home care for dementia patients that have resulted in the patient being institutionalised.



Objectives

To determine the reasons for placing the dementia patient in an institution.



Resources

Self-administered questionnaire of 48 questions on the patient and caregiver, including a list of complaints, given to the main caregiver. Medical questionnaire on the patient filled in by the geriatrician.



Results

Data were collected from 109 questionnaires concerning 75 females with dementia (84.7 ± 6.7 years) and 34 demented males (80.8 ± 7.4 years). In two-thirds of cases the main caregiver was a female, aged 61.1 ± 12.1 years. Cognitive disorders were not the main reasons for institutionalising patients. The most frequent caregiver complaint at the time of institutionalisation was incontinence, followed by withdrawal. The caregiver's main problem resulting in institutionalisation was dependence, with behavioural disorders in second place. A treatment with anticholinesterase for dementia was associated with a live-in carer being provided for 20 months longer than in the case of patients not receiving this treatment. Statistical analysis revealed 6 groups of separate caregiver-patient situations. On the one hand there were those patients who appeared to be easy for the caregiver to cope with: those with no problems, docile patients and passive patients not opposing care. In these cases the caregiver was most often young and male, or not directly related to the patient. On the other hand there were 3 other groups: patients with inappropriate motor behaviours, violent/agitated patients and unmotivated patients who opposed care. These patients lived with an elderly caregiver who had been looking after the patient for several years.



Discussion

Caregivers' requirements are for help with coping with and preventing dependence. The caregiver suffers terribly from a lack of relief, particularly when young.



Conclusion

It is necessary to change the focus of home care for dementia patients towards preventing loss of autonomy and its consequences and to allow for periods of relief for home caregivers. Copyright © 2004 John Wiley & Sons, Ltd.

Reasons of informal caregivers for institutionalising dementia patients previously living at home: the Pixel study

Context
Prospective study of the complaints, problems and requirements of the main caregiver providing home care for dementia patients.

Objectives
To determine the complaints of home caregivers, how they are interrelated and what causes them.

Resources
Self-administered questionnaire of 42 questions on the patient and caregiver, including a list of complaints, given to the main caregiver. Medical questionnaire on the patient filled in by the attending physician, usually a specialist, freelance or salaried doctor.

Results
408 sets of records were compiled, concerning 236 demented women (77.1 ± 0.47 years) and 172 demented men (75.7 ± 0.57 years). In two-thirds of cases, the main caregiver was a woman aged 60.6 ± 0.79 years. Female caregivers were more vulnerable than male caregivers. The most frequent caregiver complaint, regardless of the stage of the disease, concerned loss of motivation and withdrawal. The patient's awareness of the disorder was accompanied by a reduction in motor dysfunction and aggressiveness, but associated with a higher frequency of the complaint regarding loss of motivation reported by the caregiver. The caregivers' problems concerned mainly the absence of relief and the impossibility of having any time to themselves. Caregivers' requests for information concerned medical information, care structures and day care facilities.

Discussion
The attending physician comes into close contact with the patient, but must take into account the patient's environment. The physician can provides a separate analysis to the caregiver and does not completely answer to certain family questions or needs. He or she is not the family's prime source of information. The caregivers' requirements relate to the areas that are the attending physician's responsibility: the development and characteristics of the disease. The caregiver is anxious about the patient's future and is trapped by his or her involvement in the care, suffering greatly from the lack of relief.

Conclusions
It is necessary to change the focus of home care for dementia patients to fit the context in which they live and to allow for periods of relief for home caregivers. Copyright © 2002 John Wiley & Sons, Ltd.

Complaints of informal caregivers providing home care for dementia patients: the Pixel study.

La mauvaise sante des aidants, leur âge, leur solitude et leur charge en soin aupres du dement entrainent leur vulnerabilite. Objectif : cette etude vise a determiner les parametres influencant la vulnerabilite et la qualite de vie des aidants, et a mesurer leurs consequences. Methodes : une grille de qualite de vie des aidants et une grille de vulnerabilite ont ete developpees a partir des donnees des etudes Pixel precedentes. Chacune se presente sous la forme d’un auto-questionnaire a 20 items. Leurs resultats ont ete mis en relation avec des donnees socio-demographiques concernant le malade et son aidant principal, ainsi qu’avec les donnees medicales et therapeutiques. Resultats : 1 410 questionnaires portant sur le malade et son aidant principal ont ete colliges. La qualite de vie des aidants etait liee a leur vulnerabilite. Les femmes avaient une plus mauvaise qualite de vie et etaient dans des situations plus precaires que les hommes. Qualite de vie et vulnerabilite des aidants etaient favorablement influencees par la therapeutique specifique de la demence. La vulnerabilite de l’aidant allait de pair avec l’etat nutritionnel mediocre du malade. La population des aidants fragiles associait mauvaise qualite de vie et vulnerabilite et etait souvent elle-meme confrontee a des problemes de sante. Elle etait aussi moins satisfaite de ses efforts dans le soin et de sa relation avec la personne malade. Discussion : qualite de vie et vulnerabilite des aidants sont liees, meme si l’une et l’autre refletent leur detresse. La therapeutique de la demence est benefique aux deux. On peut penser que ce benefice est potentialise par une bonne prise en charge de l’aidant comme du malade.

Cyril Hazif-Thomas

Papers

Dementia patients caregivers quality of life: the PIXEL study.

Family, Alzheimer's disease and negative symptoms.

Reasons of informal caregivers for institutionalising dementia patients previously living at home: the Pixel study

Complaints of informal caregivers providing home care for dementia patients: the Pixel study.

La vulnérabilité de l’aidant principal des malades déments à domicile. L’étude Pixel