OBJECTIVES: The goal of this study was to project the future prevalence and incidence of Alzheimer's disease in the United States and the potential impact of interventions to delay disease onset. METHODS: The numbers of individuals in the United States with Alzheimer's disease and the numbers of newly diagnosed cases that can be expected over the next 50 years were estimated from a model that used age-specific incidence rates summarized from several epidemiological studies, US mortality rates, and US Bureau of the Census projections. RESULTS: in 1997, the prevalence of Alzheimer's disease in the United States was 2.32 million (range: 1.09 to 4.58 million); of these individuals, 68% were female. It is projected that the prevalence will nearly quadruple in the next 50 years, by which time approximately 1 in 45 Americans will be afflicted with the disease. Currently, the annual number of new incident cases in 360,000. If interventions could delay onset of the disease by 2 years, after 50 years there would be nearly 2 million fewer cases than projected; if onset could be delayed by 1 year, there would be nearly 800,000 fewer prevalent cases. CONCLUSIONS: As the US population ages, Alzheimer's disease will become an enormous public health problem. interventions that could delay disease onset even modestly would have a major public health impact.

/pdf/projections-of-alzheimer-s-disease-in-the-united-states-and-4qywzd3dsk.pdf

Projections of Alzheimer's disease in the United States and the public health impact of delaying disease onset.

Background The e4 allele of the apolipoprotein E gene (APOE) is the chief known genetic risk factor for Alzheimer's disease, the most common cause of dementia late in life. To determine the relation between brain responses to tasks requiring memory and the genetic risk of Alzheimer's disease, we performed APOE genotyping and functional magnetic resonance imaging (MRI) of the brain in older persons with intact cognition. Methods We studied 30 subjects (age, 47 to 82 years) who were neurologically normal, of whom 16 were carriers of the APOE e4 allele and 14 were homozygous for the APOE e3 allele. The mean age and level of education were similar in the two groups. Patterns of brain activation during functional MRI scanning were determined while subjects memorized and recalled unrelated pairs of words and while subjects rested between such periods. Memory was reassessed in 14 subjects two years later. Results Both the magnitude and the extent of brain activation during memory-activation tasks in regions affe...

/pdf/patterns-of-brain-activation-in-people-at-risk-for-alzheimer-164a4pgy30.pdf

Patterns of brain activation in people at risk for Alzheimer's disease

ContextNeuropsychiatric symptoms of dementia are common and associated with
poor outcomes for patients and caregivers. Although nonpharmacological interventions
should be the first line of treatment, a wide variety of pharmacological agents
are used in the management of neuropsychiatric symptoms; therefore, concise,
current, evidence-based recommendations are needed.ObjectiveTo evaluate the efficacy of pharmacological agents used in the treatment
of neuropsychiatric symptoms of dementia.Evidence AcquisitionA systematic review of English-language articles published from 1966
to July 2004 using MEDLINE, the Cochrane Database of Systematic Reviews, and
a manual search of bibliographies was conducted. Inclusion criteria were double-blind,
placebo-controlled, randomized controlled trials (RCTs) or meta-analyses of
any drug therapy for patients with dementia that included neuropsychiatric
outcomes. Trials reporting only depression outcomes were excluded. Data on
the inclusion criteria, patients, methods, results, and quality of each study
were independently abstracted. Twenty-nine articles met inclusion criteria.Evidence SynthesisFor typical antipsychotics, 2 meta-analyses and 2 RCTs were included.
Generally, no difference among specific agents was found, efficacy was small
at best, and adverse effects were common. Six RCTs with atypical antipsychotics
were included; results showed modest, statistically significant efficacy of
olanzapine and risperidone, with minimal adverse effects at lower doses. Atypical
antipsychotics are associated with an increased risk of stroke. There have
been no RCTs designed to directly compare the efficacy of typical and atypical
antipsychotics. Five trials of antidepressants were included; results showed
no efficacy for treating neuropsychiatric symptoms other than depression,
with the exception of 1 study of citalopram. For mood stabilizers, 3 RCTs
investigating valproate showed no efficacy. Two small RCTs of carbamazepine
had conflicting results. Two meta-analyses and 6 RCTs of cholinesterase inhibitors
generally showed small, although statistically significant, efficacy. Two
RCTs of memantine also had conflicting results for treatment of neuropsychiatric
symptoms.ConclusionsPharmacological therapies are not particularly effective for management
of neuropsychiatric symptoms of dementia. Of the agents reviewed, the atypical
antipsychotics risperidone and olanzapine currently have the best evidence
for efficacy. However, the effects are modest and further complicated by an
increased risk of stroke. Additional trials of cholinesterase inhibitors enrolling
patients with high levels of neuropsychiatric symptoms may be warranted.

/pdf/pharmacological-treatment-of-neuropsychiatric-symptoms-of-5fneydzs9c.pdf

Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence.

A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment.

ContextExercise training for patients with Alzheimer disease combined with
teaching caregivers how to manage behavioral problems may help decrease the
frailty and behavioral impairment that are often prevalent in patients with
Alzheimer disease.ObjectiveTo determine whether a home-based exercise program combined with caregiver
training in behavioral management techniques would reduce functional dependence
and delay institutionalization among patients with Alzheimer disease.Design, Setting, and PatientsRandomized controlled trial of 153 community-dwelling patients meeting
National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer
Disease and Related Disorders Association criteria for Alzheimer disease,
conducted between June 1994 and April 1999.InterventionsPatient-caregiver dyads were randomly assigned to the combined exercise
and caregiver training progam, Reducing Disability in Alzheimer Disease (RDAD),
or to routine medical care (RMC). The RDAD program was conducted in the patients'
home over 3 months.Main Outcome MeasuresPhysical health and function (36-item Short-Form Health Survey's [SF-36]
physical functioning and physical role functioning subscales and Sickness
Impact Profile's Mobility subscale), and affective status (Hamilton Depression
Rating Scale and Cornell Depression Scale for Depression in Dementia).ResultsAt 3 months, in comparison with the routine care patients, more patients
in the RDAD group exercised at least 60 min/wk (odds ratio [OR], 2.82; 95%
confidence interval [CI], 1.25-6.39; P = .01) and
had fewer days of restricted activity (OR, 3.10; 95% CI, 1.08-8.95; P<.001). Patients in the RDAD group also had improved
scores for physical role functioning compared with worse scores for patients
in the RMC group (mean difference, 19.29; 95% CI, 8.75-29.83; P<.001). Patients in the RDAD group had improved Cornell Depression
Scale for Depression in Dementia scores while the patients in the RMC group
had worse scores (mean difference, −1.03; 95% CI, −0.17 to −1.91; P = .02). At 2 years, the RDAD patients continued to have
better physical role functioning scores than the RMC patients (mean difference,
10.89; 95% CI, 3.62-18.16; P = .003) and showed a
trend (19% vs 50%) for less institutionalization due to behavioral disturbance.
For patients with higher depression scores at baseline, those in the RDAD
group improved significantly more at 3 months on the Hamilton Depression Rating
Scale (mean difference, 2.21; 95% CI, 0.22-4.20; P =
.04) and maintained that improvement at 24 months (mean difference, 2.14;
95% CI, 0.14-4.17; P = .04).ConclusionExercise training combined with teaching caregivers behavioral management
techniques improved physical health and depression in patients with Alzheimer
disease.

/pdf/exercise-plus-behavioral-management-in-patients-with-ln19xem99p.pdf

Exercise Plus Behavioral Management in Patients With Alzheimer Disease: A Randomized Controlled Trial

Objective. —A consensus conference on the diagnosis and treatment of Alzheimer disease (AD) and related disorders was organized by the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society on January 4 and 5, 1997. The target audience was primary care physicians, and the following questions were addressed: (1) How prevalent is AD and what are its risk factors? What is its impact on society? (2) What are the different forms of dementia and how can they be recognized? (3) What constitutes safe and effective treatment for AD? What are the indications and contraindications for specific treatments? (4) What management strategies are available to the primary care practitioner? (5) What are the available medical specialty and community resources? (6) What are the important policy issues and how can policymakers improve access to care for dementia patients? (7) What are the most promising questions for future research? Participants. —consensus panel members and expert presenters were drawn from psychiatry, neurology, geriatrics, primary care, psychology, nursing, social work, occupational therapy, epidemiology, and public health and policy. Evidence. —The expert presenters summarized data from the world scientific literature on the questions posed to the panel. Consensus Process. —The panelists listened to the experts' presentations, reviewed their background papers, and then provided responses to the questions based on these materials. The panel chairs prepared the initial drafts of the consensus statement, and these drafts were read by all panelists and edited until consensus was reached. Conclusions. —Alzheimer disease is the most common disorder causing cognitive decline in old age and exacts a substantial cost on society. Although the diagnosis of AD is often missed or delayed, it is primarily one of inclusion, not exclusion, and usually can be made using standardized clinical criteria. Most cases can be diagnosed and managed in primary care settings, yet some patients with atypical presentations, severe impairment, or complex comorbidity benefit from specialist referral. Alzheimer disease is progressive and irreversible, but pharmacologic therapies for cognitive impairment and nonpharmacologic and pharmacologic treatments for the behavioral problems associated with dementia can enhance quality of life. Psychotherapeutic intervention with family members is often indicated, as nearly half of all caregivers become depressed. Health care delivery to these patients is fragmented and inadequate, and changes in disease management models are adding stresses to the system. New approaches are needed to ensure patients' access to essential resources, and future research should aim to improve diagnostic and therapeutic effectiveness.

http://www.radford.edu/~jcsteele/Psyc230Spr2007/AD/Diagnosistreatment.pdf

Diagnosis and treatment of Alzheimer disease and related disorders. Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society.

The Institute of Medicine has formed a Committee on Improving Quality in Long-Term Care, which is examining the legislative and quality-of-care impact that the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) had on long-term care. The American Psychiatric Association and the American Association for Geriatric Psychiatry were asked to provide written and oral testimony before the Committee in March 1998. The two organizations summarized the key outcomes of OBRA '87 on the psychiatric needs of individuals who receive services in long-term care settings. The written testimony also encouraged the Committee to insist that the long-term care industry develop, test, and refine psychiatric and mental health quality outcome measures for nursing facilities and other long-term care settings.

The Impact of OBRA '87 on Psychiatric Services in Nursing Homes: Joint Testimony of The American Psychiatric Association and The American Association for Geriatric Psychiatry

Joel E. Streim

Papers

Diagnosis and treatment of Alzheimer disease and related disorders. Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer's Association, and the American Geriatrics Society.

The Impact of OBRA '87 on Psychiatric Services in Nursing Homes: Joint Testimony of The American Psychiatric Association and The American Association for Geriatric Psychiatry