Clinical criteria for the diagnosis of Alzheimer's disease include insidious onset and progressive impairment of memory and other cognitive functions. There are no motor, sensory, or coordination deficits early in the disease. The diagnosis cannot be determined by laboratory tests. These tests are important primarily in identifying other possible causes of dementia that must be excluded before the diagnosis of Alzheimer's disease may be made with confidence. Neuropsychological tests provide confirmatory evidence of the diagnosis of dementia and help to assess the course and response to therapy. The criteria proposed are intended to serve as a guide for the diagnosis of probable, possible, and definite Alzheimer's disease; these criteria will be revised as more definitive information become available.

https://n.neurology.org/content/neurology/34/7/939.full.pdf

Clinical diagnosis of Alzheimer's disease : report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease

Background: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established. 

Methods: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality. 

Results: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline). 

Conclusions: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.

https://www.sharp.com/services/hospice/upload/phenotype5-13.pdf

Frailty in Older Adults Evidence for a Phenotype

Objectives: To develop a 10-minute cognitive screening tool (Montreal Cognitive Assessment, MoCA) to assist first-line physicians in detection of mild cognitive impairment (MCI), a clinical state that often progresses to dementia.

Design: Validation study.

Setting: A community clinic and an academic center.

Participants: Ninety-four patients meeting MCI clinical criteria supported by psychometric measures, 93 patients with mild Alzheimer's disease (AD) (Mini-Mental State Examination (MMSE) score≥17), and 90 healthy elderly controls (NC).

Measurements: The MoCA and MMSE were administered to all participants, and sensitivity and specificity of both measures were assessed for detection of MCI and mild AD.

Results: Using a cutoff score 26, the MMSE had a sensitivity of 18% to detect MCI, whereas the MoCA detected 90% of MCI subjects. In the mild AD group, the MMSE had a sensitivity of 78%, whereas the MoCA detected 100%. Specificity was excellent for both MMSE and MoCA (100% and 87%, respectively).

Conclusion: MCI as an entity is evolving and somewhat controversial. The MoCA is a brief cognitive screening tool with high sensitivity and specificity for detecting MCI as currently conceptualized in patients performing in the normal range on the MMSE.

/pdf/the-montreal-cognitive-assessment-moca-a-brief-screening-4w06t9e7qy.pdf

The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

Development and validation of a geriatric depression screening scale: A preliminary report

Food intake, appetite and a variety of feelings were measured pre- and post-operatively in obese patients undergoing jejuno-ileal bypass surgery. Decreased food intake correlated closely with the amount of weight loss at both 4 and 30 months after surgery. Malabsorption correlated with weight loss at 4 months but not 30 months post-operatively. The cause of the decreased food intake is unknown and cannot be completely explained by either depression, nausea, malabsorption, liver disease, an attempt to avert diarrhoea, or decreased appetite.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/8679F50F9E1B0A9CA902922131E28B4E/S0033291700021541a.pdf/div-class-title-reduced-caloric-intake-following-small-bowel-bypass-surgery-a-systematic-study-of-possible-causes-div.pdf

Reduced caloric intake following small bowel bypass surgery: a systematic study of possible causes

Eastern Baltimore Mental Health Survey Clinical Reappraisal

Obese subjects (N = 152) attending a weight reduction clinic and controls (N = 62) rated numerous aspects of their psychological state using analogue scales before and after a standard liquid meal. Prior to the meal, the only difference in psychological state between the groups was that the obese subjects had higher scores than controls on the questions relating to their self-perception of "fatness." Following the meal, the obese subjects, including some previously obese (now normal weight) subjects, reported a decrease in "anxiety" as reflected by significant changes in premeal to postmeal scores on 5 anxiety-related questions. Control subjects tested in two separate groups, one demographically matched and one nonmatched, did not experience this "antianxiety" effect, but reported postmeal increases in feelings of "fatness" and "sexual arousal" as compared with the obese subjects.

Differential antianxiety response to caloric intake between normal and obese subjects.

In the conventional view, aging of the brain is associated with atrophy vascular abnormalities and loss of volume in hippocampus and amygdala. Cognitively, aging is associated with slowing of processing and memory loss. However, many studies of aging do not examine the cases to exclude demented people. The nutrition and memory in the homebound elderly study (NAME) excluded cases clinically diagnosed as having dementia. Cortical atrophy based on MRI ratings was significantly correlated with vascular disease, white matter hyperintensities, processing speed, and memory but not hippocampus and amygdala volume. Renal function and homocysteine were also associated with cortical atrophy but not with the cognitive variables. In conclusion, brain atrophy of aging in the absence of dementia is related to vascular disease but not hippocampal atrophy. Studies of nutritional interventions should consider using MRI atrophy rather than cognition as outcome.

Marshal F. Folstein

Papers

Reduced caloric intake following small bowel bypass surgery: a systematic study of possible causes

Eastern Baltimore Mental Health Survey Clinical Reappraisal

Differential antianxiety response to caloric intake between normal and obese subjects.

Functional expressions of the aging brain

Nursing Assessment of Mental Disorders On A General Medical Unit