Showing papers in "International Journal of Geriatric Psychiatry in 2004"

DemTect: a new, sensitive cognitive screening test to support the diagnosis of mild cognitive impairment and early dementia

Abstract: Objectives To design a new, highly sensitive psychometric screening to identify patients with mild cognitive impairment (MCI) and patients with dementia in the early stages of the disease. Methods Five tasks were included in the DemTect: a word list, a number transcoding task, a word fluency task, digit span reverse, and delayed recall of the word list. The normation was performed with 145 healthy control subjects (CG). Furthermore, 97 MCI patients and 121 patients with possible Alzheimer's disease (AD) were tested with the DemTect and the MMSE. Classification rates for both tests were analysed. Results On the basis of the CG data, age-dependant transformation algorithms for the DemTect subtests were defined, and an education correction was provided for the total transformed score. The patient groups scored significantly below the CG in both the DemTect and the MMSE. Compared to the MMSE, classification rates of the DemTect were superior for both the MCI and the AD group, with high sensitivities of 80% and 100%, respectively. Conclusions The DemTect is short (8–10 minutes), easy to administer, and its transformed total score (maximum 18) is independent of age and education. The DemTect helps in deciding whether cognitive performance is adequate for age (13–18 points), or whether MCI (9–12 points) or dementia (8 points or below) should be suspected. Copyright © 2004 John Wiley & Sons, Ltd.

The criterion validity of the Center for Epidemiological Studies Depression Scale (CES‐D) in a sample of self‐referred elders with depressive symptomatology

Abstract: Background The criterion validity of the Center for Epidemiological Studies Depression scale (CES-D) was assessed in a group of elderly Dutch community-residents who were self-referred to a prevention program for depression. Methods Paper-and-pencil administration of the CES-D to 318 elders (55–85 years). Criterion validity was evaluated with the Mini International Neuropsychiatric Interview (MINI), a clinical diagnostic interview based on DSM-IV. Sensitivity and specificity for various cut-off scores of CES-D were compared with the DSM-IV major depressive disorder (MDD) and with clinically relevant depression (CRD), a composite diagnosis of MDD, subthreshold depression or dysthymia. Furthermore the characteristics of true versus false positives were analyzed. Results For MDD, the optimal cut-off score was 25, (sensitivity 85%, specificity 64%, and positive predicted value of 63%). For CRD, the optimal cut-off was 22 (sensitivity 84%, specificity 60%, and positive predicted value 77%). True positives, MDD and CRD, reported significantly more anxiety symptomatology and more co-morbid anxiety disorders, false positives reported more previous depressive episodes. Conclusions The criterion validity of the CES-D for MDD and CRD was satisfactory in this semi-clinical sample of elders. Subjects scoring ≥25 constitute a target group for further diagnostic assessment in order to determine appropriate treatment. Copyright © 2004 John Wiley & Sons, Ltd.

Disclosing a diagnosis of dementia: a systematic review

Abstract: Background: the issue of diagnostic disclosure in dementia has been debated extensively in professional journals, but empirical data concerning disclosure in dementia has not previously been systematically reviewed. Objective: to review empirical data regarding diagnostic disclosure in dementia. Methods: five electronic databases were searched up to September 2003 (Medline, Embase, Cinahl, Sociological Abstracts, Web of Science). Additional references were identified through hand searches of selected journals and bibliographies of relevant articles and books. The title and abstract of each identified paper were reviewed independently by two reviewers against pre-determined inclusion criteria: original data about disclosure were presented and the paper was in English. Any disagreements were resolved by discussion until consensus was reached. Data were extracted independently by two reviewers using a structured abstraction form. Data quality were not formally assessed although each study was critically reviewed in terms of methodology, sampling criteria, response rates and appropriateness of analysis. Results: fifty-nine papers met the inclusion criteria for detailed review. Many of the studies had methodological shortcomings. The studies reported wide variability in all areas of beliefs and attitudes to diagnostic disclosure and reported practice. Studies of the impact of disclosure indicate both negative and positive consequences of diagnostic disclosure for people with dementia and their carers. Conclusions: existing evidence regarding diagnostic disclosure in dementia is both inconsistent and limited with the perspectives of people with dementia being largely neglected. This state of knowledge seems at variance with current guidance about disclosure

Care arrangements for people with dementia in developing countries.

Abstract: BACKGROUND: Rapid demographic ageing will soon lead to large increases in the numbers of persons with dementia in developing countries. This study is the first comprehensive assessment of care arrangements for people with dementia in those regions. METHODS: A descriptive and comparative study of dementia care; caregiver characteristics, the nature of care provided, and the practical, psychological (Zarit Burden Interview, General Health Questionnaire) and economic impact upon the caregiver in 24 centres in India, China and South East Asia, Latin America and the Caribbean and Africa. RESULTS: We interviewed 706 persons with dementia, and their caregivers. Most caregivers were women, living with the person with dementia in extended family households. One-quarter to one-half of households included a child. Larger households were associated with lower caregiver strain, where the caregiver was co-resident. However, despite the traditional apparatus of family care, levels of caregiver strain were at least as high as in the developed world. Many had cutback on work to care and faced the additional expense of paid carers and health services. Families from the poorest countries were particularly likely to have used expensive private medical services, and to be spending more than 10% of the per capita GNP on health care. CONCLUSIONS: Older people in developing countries are indivisible from their younger family members. The high levels of family strain identified in this study feed into the cycle of disadvantage and should thus be a concern for policymakers in the developing world.

Patient versus informant perspectives of Quality of Life in Mild Cognitive Impairment and Alzheimer's disease

Abstract: Background Prior studies on Quality of Life (QOL) in Alzheimer's disease (AD) have rarely included control participants, or participants with very mild levels of cognitive impairment. Furthermore, there is little data to indicate whether or not mildly impaired patients can provide self-report QOL data or if informant reports are needed. Objectives This study compared QOL ratings from informants and patients with mild AD (n = 26), Mild Cognitive Impairment (MCI, n = 30), and elderly controls (n = 23). Methods Participants (aged 60–91 years) were recruited from an outpatient memory disorder clinic. Elderly controls were recruited from the community. Measures about patients were the Dementia Quality of Life scale, the Neuropsychiatric Inventory—Questionnaire, Instrumental of Activities of Daily Living, and Mini-mental State Exam. Informant depression was assessed with the Geriatric Depression Scale. Results Results indicated that overall patient-informant agreement for MCI (M=0.24), AD (M=0.48), and controls (M=0.49) did not differ significantly. Self-reported QOL did not differ significantly across the 3 groups. For caregiver-reports, QOL in MCI again did not differ from controls but was significantly greater than QOL in AD for 2 of 6 scales, and QOL in controls was greater than AD for 4 of 6 scales. Regression analyses indicated that neuropsychiatric symptoms were the most consistent predictors of QOL. Conclusions In summary, informant- and self-perceptions of QOL differed substantially. Results suggest that future investigators should carefully consider gathering QOL information from both informants and patients because they provide unique information regarding patient QOL and, to date, neither source of information has been established to be superior. Copyright © 2004 John Wiley & Sons, Ltd.

Randomized placebo-controlled trial of donepezil in cognitive impairment in Parkinson's disease.

Abstract: Objective To evaluate the efficacy and safety of donepezil, an acetylcholinesterase inhibitor, as a treatment for cognitive impairment and dementia in patients with Parkinson' s disease (PD). Methods Using a randomized, double-blind, placebo-controlled design, nine patients received placebo and seven patients received donepezil (2.5–10 mg/day) for a mean (SD) duration of 15.2 (3.4) weeks. The primary efficacy outcomes were derived from a neuropsychological battery that assessed global cognitive status as well as memory, attention, psychomotor speed, and visuospatial and executive functions. Secondary efficacy outcomes were psychiatric symptom and activities of daily living ratings. Primary safety measures were motor signs and assessments of adverse effects. Results Patients on donepezil showed selective and significant (p<0.05) improvement on the memory subscale of the Dementia Rating Scale. There was also a trend toward improvement on a measure of psychomotor speed and attention. There were no group differences in psychiatric status, motor function, or activities of daily living as measured at baseline or end-point. Adverse effects resulted in premature withdrawal of four patients on donepezil, two for peripheral cholinergic effects and one for increased parkinsonism. Side effects were associated with dosage increases. Conclusion Donepezil has a beneficial effect on memory and may improve other cognitive deficits in patients with PD and cognitive impairment. However, variable tolerability in our sample underscores the need for careful monitoring when prescribing donepezil to patients with PD, especially with dosage increases. Copyright © 2004 John Wiley & Sons, Ltd.

Knowledge of Alzheimer's disease in four ethnic groups of older adults.

Abstract: Objectives The present study evaluated knowledge of Alzheimer's disease (AD) in four ethnic groups of older adults. Methods Ninety-six Anglo, 37 Latino, 30 Asian, and 30 African American older adults completed a short survey about AD. Results Results indicated that Anglo older adults are significantly more knowledgeable about AD than African American, Asian, and Latino older adults. Level of education partially accounted for differences in knowledge of AD between Latino to Anglo older adults. After controlling for age, number of years of speaking English was associated with knowledge of AD in Asian older adults. Conclusions The results suggest that certain ethnic minority groups do not have sufficient information about AD, and this may explain the lack of AD service use by minorities. Extensive evaluation of barriers to knowledge of AD is needed in order to specifically target minority groups and educate them about AD and the importance of early intervention. Copyright © 2004 John Wiley & Sons, Ltd.

Adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture.

Abstract: Objectives This study examines the effects of depression and cognitive impairment in elderly hip fracture patients receiving inpatient rehabilitation. Our goal was to determine whether any association of depression and cognitive impairment with rehabilitation outcome is accounted for by more immediate effects of these variables on rehabilitation participation. Methods We measured depression using the Hamilton Rating Scale for Depression (Ham-D), cognition using the Mini Mental State Examination (MMSE), and rehabilitation outcomes using the motor scale of the Functional Independence Measure (motor FIM) in a prospective observational study of 57 elderly rehabilitation hospital patients admitted to a university-affiliated, freestanding rehabilitation hospital with primary diagnosis of hip fracture. We also assessed rehabilitation participation, to determine whether this accounted for (mediated) any relationship of depression and cognitive impairment with rehabilitation outcome. Results Baseline Ham-D and MMSE scores were correlated with motor FIM efficiency—those with higher depressive symptoms had lower efficiency (r = −0.44, p < 0.001); similarly, those with more cognitive impairment had lower motor FIM efficiency (r = 0.52, p < 0.001). Rehabilitation participation was a mediator of this association: greater depressive symptoms and cognitive impairment predicted poorer rehabilitation participation which, in turn, predicted lower motor FIM efficiency. Ham-D and MMSE scores were predictors of discharge location: subjects with high depressive symptoms and greater cognitive impairment were more likely to go to a nursing home or personal care home upon discharge. Conclusions Depression and cognitive impairment are predictive of negative outcomes in elderly patients' rehabilitation from hip fracture. This effect is mediated by rehabilitation participation, and ratings in this area may serve as a potentially useful clinical and research tool for the rehabilitation environment. Copyright © 2004 John Wiley & Sons, Ltd.

Do caregiver management strategies influence patient behaviour in dementia

Abstract: Objectives Little is known about the effectiveness of caregiver management strategies on the functioning of the demented patient. However, identification of specific caregiver strategies may provide useful information on the management and manifestation of behavioural problems in dementia. Methods Ninety-nine patients with dementia and their informal caregivers were followed up for one year. Interviews were used to assess differences in caregiver management strategies. Behavioural disturbances in the patient were measured with the Neuropsychiatric Inventory (NPI). Repeated measures analysis were carried out to investigate the relationship between caregiver management strategies and patient behaviour. Results Three caregiver management strategies were identified, based on whether caregivers accepted, or not, the caregiving situation and dementia related problems. Caregivers characterized by non-acceptance were typified as ‘Non-adapters’; caregivers characterized by acceptance were further subdivided into two groups typified as ‘Nurturers’ and ‘Supporters’. Caregiver characteristics such as sex, education and personality were important determinants of management strategies. MANOVA showed that non-adapters reported significantly more hyperactivity symptoms in patients and felt less competent than did supporters. Conclusions Caregiver management strategies would appear to be associated with behavioural problems in dementia, and are important in predicting patient behaviour and caregiver burden. Intervention programmes should aim at teaching caregivers adequate management strategies. Copyright © 2004 John Wiley & Sons, Ltd.

Olanzapine versus placebo in the treatment of psychosis with or without associated behavioral disturbances in patients with Alzheimer's disease

Abstract: Objectives Psychotic symptoms and behavioral disturbances are a concern in the care of elderly patients with Alzheimer's dementia (AD). This study was conducted to compare the efficacy of olanzapine versus placebo in patients with psychotic symptoms associated with AD in long-term or continuing-care settings. Methods Patients (n = 652) with AD and delusions or hallucinations were randomly assigned to 10 weeks of double-blind treatment with placebo or fixed-dose olanzapine (1.0, 2.5, 5.0, 7.5 mg/day). Results Mean age was 76.6±10.4 years. Repeated-measures analysis showed significant improvement from baseline in NPI/NH Psychosis Total scores (sum of Delusions, Hallucinations items—primary efficacy measure) in all five treatment groups (p<0.001), but no pairwise treatment differences were seen at the 10-week endpoint. However, under LOCF analysis, improvement in the 7.5 mg olanzapine group (−6.2 ± 4.9) was significantly greater than with placebo (−5.0 ± 6.1, p = 0.008), while endpoint CGI-C scores showed the greatest improvement in the Olz 2.5 olanzapine group (2.8 ± 1.4, p = 0.030) relative to placebo (3.2 ± 1.4). There were significant overall treatment-group differences in increased weight, anorexia, and urinary incontinence, with olanzapine showing numerically higher incidences. However, neither the incidence of any other individual events, including extrapyramidal symptoms, nor of total adverse events occurred with significantly higher frequency in any olanzapine group relative to placebo. No clinically relevant significant changes were seen across groups in cognition or any other vital sign or laboratory measure, including glucose, triglyceride, and cholesterol. Conclusions While 1.0 mg olanzapine did not show significant differences from placebo, the 2.5 mg dose was a reasonable starting dose. Olanzapine at 7.5 mg/day significantly decreased psychosis and overall behavioral disturbances (NPI/NH, BPRS) and was well tolerated. Copyright © 2004 John Wiley & Sons, Ltd.

Topographical disorientation in community-residing patients with Alzheimer's disease.

Abstract: Background Based on the hypothesis that declarative memory and navigation ability depend on hippocampal integrity, and the fact that declarative memory declines early in Alzheimer's disease (AD), the authors suggest that topographical disorientation (TD) will be an early manifestation of AD. Subjects and methods Patients diagnosed with AD based on DSM-IV criteria, residing at home, were studied in a clinic at a 1000-bed referral medical center. Patient characteristics, disease condition, performance on neuropsychological tests, and navigation function were compared between patients with and without current TD. Information regarding the extent and duration of TD and the level of current navigational function were collected during a clinical interview. Results 112 patients (61 males and 51 females) with mean age of 74 years and disease duration of 37 months completed the study. Among them, 61 currently experienced TD, 20 had required an escort to their home by others, and 28 had TD as an incipient symptom. Those with current TD tended to have a longer disease duration, required an escort to their home by others, and reported a history of repeated change of residence, TD as an incipient symptom, a restricted spatial range within which they felt comfortable (safety range), and disorientation when they were out of familiar territory. In addition, care-givers reported a high level of concern for the safety of those with TD when he or she traveled alone. Conclusion TD in community-dwelling AD patient is common. Caregivers should pay attention to those with longer disease duration and try to avoid changing residence. Developing a brief and valid test for topographical orientation will be helpful for the early detection of TD. Copyright © 2004 John Wiley & Sons, Ltd.

The persistence of neuropsychiatric symptoms in dementia: the Cache County Study.

Abstract: Objective To estimate the 18-month persistence of neuropsychiatric symptoms in dementia in a population-based sample, and to compare the severity of neuropsychiatric symptoms at baseline to the severity at 18-month follow-up. Methods A population-based sample of 329 residents of Cache County, Utah, diagnosed with dementia was rated on the Neuropsychiatric Inventory (NPI). Of the 204 participants with neuropsychiatric symptoms at baseline (defined as total NPI score >0), NPI data were obtained approximately 18 months later on 117 who were alive and available for follow-up. Results Eighty-one percent of those with neuropsychiatric symptoms at baseline (defined as total NPI score>0) continued to have at least one symptom at follow-up. Sixty-seven percent of participants with a clinically significant total NPI score (defined as ≥;4) at baseline continued to have a clinically significant total NPI score at follow-up. Among the ten neuropsychiatric domains assessed at baseline, delusions persisted in 65.5% of individuals, followed by depression (58.3%), and aberrant motor behavior (55.6%), while hallucinations and disinhibition persisted in only 25.0% and 11.1% respectively. In participants who were symptomatic at both baseline and follow-up, the mean severity scores at the two observation points were comparable in all ten neuropsychiatric domains. Conclusions Neuropsychiatric symptoms in dementia overall were highly persistent. Among those in whom symptoms did persist, symptom severity a year and a half later appeared to be comparable. Copyright © 2004 John Wiley & Sons, Ltd.

Donepezil for the symptomatic treatment of patients with mild to moderate Alzheimer's disease: a meta-analysis of individual patient data from randomised controlled trials.

Abstract: Background The objective was to evaluate the efficacy and tolerability of donepezil (5 and 10 mg/day) compared with placebo in alleviating manifestations of mild to moderate Alzheimer's disease (AD). Method A systematic review of individual patient data from Phase II and III double-blind, randomised, placebo-controlled studies of up to 24 weeks and completed by 20 December 1999. The main outcome measures were the ADAS-cog, the CIBIC-plus, and reports of adverse events. Results A total of 2376 patients from ten trials were randomised to either donepezil 5 mg/day (n = 821), 10 mg/day (n = 662) or placebo (n = 893). Cognitive performance was better in patients receiving donepezil than in patients receiving placebo. At 12 weeks the differences in ADAS-cog scores were 5 mg/day–placebo: − 2.1 [95% confidence interval (CI), − 2.6 to − 1.6; p < 0.001], 10 mg/day–placebo: − 2.5 ( − 3.1 to − 2.0; p < 0.001). The corresponding results at 24 weeks were − 2.0 ( − 2.7 to − 1.3; p < 0.001) and − 3.1 ( − 3.9 to − 2.4; p < 0.001). The difference between the 5 and 10 mg/day doses was significant at 24 weeks (p = 0.005). The odds ratios (OR) of improvement on the CIBIC-plus at 12 weeks were: 5 mg/day–placebo 1.8 (1.5 to 2.1; p < 0.001), 10 mg/day–placebo 1.9 (1.5 to 2.4; p < 0.001). The corresponding values at 24 weeks were 1.9 (1.5 to 2.4; p = 0.001) and 2.1 (1.6 to 2.8; p < 0.001). Donepezil was well tolerated; adverse events were cholinergic in nature and generally of mild severity and brief in duration. Conclusion Donepezil (5 and 10 mg/day) provides meaningful benefits in alleviating deficits in cognitive and clinician-rated global function in AD patients relative to placebo. Increased improvements in cognition were indicated for the higher dose. Copyright © 2004 John Wiley & Sons, Ltd.

Neuropsychological characteristics of mild vascular cognitive impairment and dementia after stroke.

Abstract: Background Post-stroke cognitive impairment is frequent, with characteristic impairments of attentional and executive performance. Objective The study aims to determine whether the profile and severity of impairment in vascular Cognitive Impairment No Dementia (vascular CIND) is intermediate between that seen in stroke patients without significant cognitive impairment and patients with post-stroke dementia and thus to establish if the potential value of vascular CIND is a useful concept for predicting further cognitive decline and dementia in stroke patients. Methods Stroke patients (n = 381) > 75 were recruited from representative hospital-based stroke registers in Tyneside and Wearside, UK. Sixty six age matched controls were also recruited. A detailed battery of neuropsychological assessments was completed 3 months post stroke. Results Deficits of attention (z = 5.7; p < 0.0001) and executive function (z = 5.9; p < 0.0001) were seen even in stroke patients without vascular CIND, compared to controls. However, stroke patients with CIND were significantly more impaired again on tests of executive function (z = 10.3; p < 0.0001) compared to those not meeting CIND criteria; and also had greater impairments of memory (z = 10.4; p < 0.0001) and language expression (z = 10.1; p < 0.0001). A similar overall profile of deficits was evident in the CIND and the dementia group, but specific deficits were significantly more pronounced in those with dementia, particularly in orientation (z = 7.2; p < 0.0001) and memory (z = 5.8; p < 0.0001). Conclusions The current study indicates that attentional and executive impairments are frequent in stroke patients, but deficits of memory, orientation and language are more indicative of CIND and dementia. Further longitudinal studies are required to clarify the relationship between specific lesions and the progression of specific cognitive deficits in post-stroke patients. Copyright © 2004 John Wiley & Sons, Ltd.

A randomized, placebo-controlled study of the efficacy and safety of sertraline in the treatment of the behavioral manifestations of Alzheimer's disease in outpatients treated with donepezil.

Abstract: Objective To examine the safety and efficacy of sertraline augmentation therapy in the treatment of behavioral manifestations of Alzheimer's disease (AD) in outpatients treated with donepezil. Methods and materials Patients with probable or possible AD, and a Neuropsychiatric Inventory (NPI) total score >5 (with a severity score ≥2 in at least one domain), were treated with donepezil (5–10 mg) for 8 weeks, then randomly assigned to 12 weeks of double-blind augmentation therapy with either sertraline (50–200 mg) or placebo. Primary efficacy measures were the 12-item Neuropsychiatric Inventory (NPI) and the Clinical Global Impression Improvement (CGI-I) and Severity (CGI-S) scales. Results 24 patients were treated with donepezil+sertraline and 120 patients with donepezil+placebo. There were no statistically significant differences at endpoint on any of the three primary efficacy measures. However, a linear mixed model analysis found modest but statistically significantly greater improvements in the CGI-I score on donepezil+sertraline. Moreover, in a sub-group of patients with moderate-to-severe behavioral and psychological symptoms of dementia, 60% of patients on sertraline vs 40% on placebo (p = 0.006) achieved a response (defined as ≥;50% reduction in a four-item NPI-behavioral subscale). One adverse event (diarrhea) was significantly (p < 0.05) more common in the donepezil+sertraline group compared to the donepezil+placebo group. Conclusion Sertraline augmentation was well-tolerated in this sample of AD outpatients. In addition, post hoc analyses demonstrated a modest but statistically significant advantage of sertraline over placebo augmentation in mixed model analyses and a clinically and statistically significant advantage in a subgroup of patients with moderate-to-severe behavioral and psychological symptoms of dementia. Copyright © 2004 John Wiley & Sons, Ltd.

Behavioural and psychological syndromes in Alzheimer's disease

Abstract: Objectives The origins of behavioural and psychological symptoms of dementia are still poorly understood. By focusing on piecemeal behaviours as opposed to more robust syndrome change valid biological correlates may be overlooked. Our understanding of BPSD via the identification of neuropsychiatric syndromes. Methods We recruited 435 subjects from old age psychiatry and elderly care memory outpatient clinics fulfilling the criteria for diagnosis of probable Alzheimer's disease. Behavioural and psychological symptoms were assessed using the Neuropsychiatric Inventory. Principal components factor analysis was carried out on the composite scores of the 12 symptom domains to identify behavioural syndromes (factors). Results were confirmed by performing three different rotations: Varimax, Equamax and Quartimax. Results Four factors were identified (which accounted for 57% of the variance): ‘affect’ factor—depression/dysphoria, anxiety, irritability/lability and agitation/aggression; ‘physical behaviour’ factor—apathy, aberrant motor behaviour, sleep disturbance and appetite/eating disturbance; ‘psychosis’ factor—delusions and hallucinations; ‘hypomania’ factor—disinhibition and elation/euphoria. These groups were unchanged when different methods of rotation were used. Conclusions We report novel observations that agitation/aggression/irritability cluster within a depressive symptom factor and apathy is found within a physical behaviour factor. Copyright © 2004 John Wiley & Sons, Ltd.

Brain perfusion correlates of the apathy inventory dimensions of Alzheimer's disease.

Abstract: Background Apathy is defined as a lack of motivation in behavior, cognition and affect. This syndrome is frequent in various neuropsychiatric diseases but little is known about its pathophysiology. Objectives The aim of this study was to investigate the metabolic correlates of the behavioral, cognitive and emotional, aspects of apathy in Alzheimer's disease (AD). Method< Thirty AD patients were included. Lack of initiative, lack of interest and of emotional blunting were assessed with the Apathy Inventory (IA), a tool designed to provide a separate assessment of the behavioral, cognitive and emotional, aspects of apathy. Brain perfusion was measured by 99mTc-labeled bicisate (ECD) single photon emission tomography. Results The Statistical Parametric Mapping software provides negative correlation between IA total score and brain perfusion in left and right superior orbito-frontal gyrus, and to a lesser extent in left middle frontal gyrus (BA10). Lack of initiative score was negatively correlated with perfusion in right anterior cingulate cortex. Lack of interest score was negatively correlated with perfusion in right middle orbitofrontal gyrus). Emotional blunting score correlated negatively with in left superior dorsolateral prefrontal cortex activity. Conclusion These results underline that the cognitive, behavioral and affective components of motivation are mediated by different fronto-sub-cortical circuits and are differently lateralized. In particular, left prefrontal hypoperfusion is involved in emotional blunting, as it was often demonstrated in depressive disorders. These distinct components of apathy may be targeted by different therapeutic means, in which dopaminergic enhancement might play a major role. Copyright © 2004 John Wiley & Sons, Ltd.

Obesity and depressive symptoms in Chinese elderly.

Abstract: Objectives The main objective was to examine the association between obesity and depressive symptoms among Chinese elderly in Hong Kong. Methods Cross-sectional data on depressive symptoms and body mass index from 56 167 clients aged 65 or over who enrolled as members of Elderly Health Centres from July 1998 to December 2000 were analysed using multiple logistic regression with adjustment of potential confounders. Results Among 18 750 men and 37 417 women, the prevalence [95% confidence interval (CI)] of depressive symptoms (based on the Geriatric Depression Scale) was 4.9% (4.6–5.2%) and 7.9% (7.6–8.1%) respectively (p < 0.001). The prevalence of obesity (by World Health Organisation Asian standard: body mass index ≥25.0) in women was significantly higher than that of men (42.1% (41.6–42.7%) vs 36.6% (35.9–37.3%), p < 0.001). Obese men and women were about 20% less likely to suffer from depressive symptoms compared with those with normal weight after adjustment for confounders, with odds ratios (95% CI) of 0.82 (0.69–0.97) and 0.78 (0.71–0.86) respectively. Negative linear trends were observed between depressive symptoms and BMI categories in both sexes, and women showed a greater slope and stronger statistical significance than men. Conclusions Both obese elderly men and women in Hong Kong were less likely to suffer from depressive symptoms than those of normal weight. The results support the ‘jolly fat’ hypothesis previously restricted to men, and extend the hypothesis to female elderly. Chinese traditional culture and positive values towards obesity may be protective against depressive symptoms. Copyright © 2004 John Wiley & Sons, Ltd.

A longitudinal study of Alzheimer's disease: rates of cognitive and functional decline.

Abstract: Objective To measure rates of decline in cognition and function in patients with Alzheimer's disease (AD) and to investigate their accelerating risk factors in Korea. Methods This study presents longitudinal data on a community-based sample of 107 patients with AD, followed at 6 months and 12 months. The cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog), the Mini Mental State Examination (MMSE) and the Disability Assessment for Dementia Scale (DAD) were given. Mixed model analyses were conducted using the following independent variables: times of repeated assessment (0, 6 or 12 months), severity of dementia assessed by the Functional Assessment Staging (FAST) and individual indicators as covariates. Results Average annual rates of decline in the MMSE, the ADAS-cog and the DAD were 2.3, 11.4 and 15.1 points, respectively. Neither gender, duration of formal education, nor duration of AD since onset was significant predictors of cognitive and functional decline. Patterns of functional decline in total DAD, instrumental ADLs, planning and organization and performance subscale are linear as MMSE score declines, while those of the basic ADLs and the initiation are curvilinear. Conclusion This naturalistic observational study measured rates of cognitive and functional decline in AD, and can provide reference data for further longitudinal studies or clinical trials. Further study will be necessary to determine whether linear or curvilinear pattern in functional decline is due to progression of AD itself or statistical artifact. Copyright © 2004 John Wiley & Sons, Ltd.

A randomized, controlled, clinical trial of activity therapy for apathy in patients with dementia residing in long‐term care

Abstract: Background Apathy is a common symptom in patients with dementia and has adverse consequences for patients and caregivers. Most treatments for apathy, particularly non-pharmacologic interventions, have not been evaluated in controlled trials. Objectives This study evaluated the efficacy of a kit-based activity intervention, compared to a time and attention control (one-on-one meetings with an activity therapist) in reducing apathy and improving quality of life in 37 patients with dementia. Methods The design was a randomized, controlled, partially masked clinical trial. All outcome measures were administered at baseline and follow-up. The primary outcome measure was the apathy score of the Neuropsychiatric Inventory (NPI). Other outcome measures were the NPI total score, the Alzheimer Disease Related Quality of Life scale(ADQRL), and the Copper Ridge Activity Index (CRAI). Results There was a significant reduction in NPI apathy scores in both treatment groups. The only significant difference between the two treatment groups was a modest advantage for the control intervention on the CRAI cueing subscale (p = 0.027), but not on the other CRAI subscales. There was also a greater within group improvement in quality of life ratings in the control intervention (p = 0.03). Conclusions Despite the substantial improvement in apathy scores during the course of the study, there was no clear advantage to the reminiscence-based intervention over the time and attention, one-on-one control intervention. More research is needed to develop specific behavioral interventions for apathy in patients with dementia. Copyright © 2004 John Wiley & Sons, Ltd.

Pentagon drawing and neuropsychological performance in Dementia with Lewy Bodies, Alzheimer's disease, Parkinson's disease and Parkinson's disease with dementia

Abstract: Objectives. Early and accurate diagnosis of Dementia with Lewy Bodies (DLB) to allow the appropriate clinical treatment is a priority, given reports of severe neuroleptic sensitivity and a preferential response to cholinesterase inhibitors in these patients. There have been suggestions that constructional apraxia is prevalent in DLB, and may provide a sensitive marker of the disease. Methods. This study examined the pentagon drawings of 100 DLB patients, 50 Alzheimer's disease (AD) patients, 81 Parkinson's disease (PD) patients of whom 36 suffered from dementia (PDD). Performance on this task was correlated with cognitive performance on the MMSE and CAMCOG scales. Results. Patients with DLB were found to draw significantly worse pentagons than those with AD or PD, but not those with PDD. Drawing scores were significantly correlated with MMSE scores for the AD and PDD groups but not those with DLB. More detailed analysis of the neuropsychological correlates of constructional performance for patients with AD and DLB, revealed that those with AD showed a broad cognitive basis to their impairment, in DLB drawing was linked only to perception and praxis. Conclusions. This study has suggests that DLB subjects show an impairment of pentagon copying that is dissociable from more global cognitive impairments, whereas PD patients are relatively unimpaired on pentagon copying and AD and PDD patients show a linkage of their impairment in copying with more global cognitive deficits.

Prevalence of major and minor depression in elderly persons with mild cognitive impairment--MADRS factor analysis.

Abstract: Objective The aim of the study was to detect the prevalence of depressive syndromes and symptoms in the sample of elderly persons with Mild Cognitive Impairment (MCI), and to analyse Montgomery-Asberg Depression Rating (MADRS) item scores. Method The subjects of the study were 102 consecutive out-patients with MCI. All subjects were assessed by an experienced psychiatrist and MADRS was applied. Major and minor depressive episodes were defined according to DSM-IV criteria. Factor analysis was used to analyse baseline MADRS item scores. Results Three patient groups emerged according to the depressive symptoms distribution and severity scores basis: those with major depression constituted 19.6% (n = 20), with minor depression 26.5% (n = 27), and with very few depressive symptoms 53.9% (n = 55). Three interpretable MADRS factors were identified, using the factor analysis with Varimax rotation: the first consisting of apparent and reported sadness, inability to feel, pessimistic thoughts, the second consisting of inner tension, reduced sleep, reduced appetite, suicidal thoughts, and the third with concentration difficulties and lassitude. Conclusions It was concluded that both major and minor depression is common in MCI. Three MADRS factors were identified and labelled as anhedonia-pessimism, anxiety-vegetative, and cognitive-inhibition. Copyright © 2004 John Wiley & Sons, Ltd.

Validity of the Telephone Interview for Cognitive Status (TICS) in post-stroke subjects.

Abstract: Background Cognitive impairment and dementia are very common after stroke. Telephone screening has potential advantages for clinical follow-up and population-based research in this group. We wished to test the validity of the Telephone Interview for Cognitive Status (TICS) for cognitive testing in post-stroke subjects. Methods Cognitive function in stroke outpatients was assessed using the R-CAMCOG (a modification of the cognitive part of the Cambridge Examination for Mental Disorders of the Elderly, for use in stroke subjects) along with the TICS and a modified version, the TICSm. The tests were administered in random order. A cut-off point of 33 on the R-CAMCOG was used to define post-stroke dementia. Results Sixty-four patients with a median age of 72 years were assessed. The Pearson correlation coefficients between the R-CAMCOG and the TICS and TICSm were 0.833 and 0.855 (both p <0.001) respectively. Twenty-four (38%) patients met R-CAMCOG criteria for post-stroke dementia. The area under the ROC curve for both the TICS and TICSm was 0.94. Using a cut-off of 28 or less on the TICS produced a sensitivity of 88% and a specificity of 85% for the diagnosis of post-stroke dementia. For the TICSm a cut-off of 20 or lower produced a sensitivity of 92% and a specificity of 80%. Conclusions The TICS and TICSm telephone questionnaires are practicable and valid methods of assessing cognitive function in community outpatients following stroke. Scores of ≤28 and ≤20 respectively carry good sensitivity and specificity for the diagnosis of post-stroke dementia. Copyright © 2004 John Wiley & Sons, Ltd.

A multinational, randomised, 12‐week study comparing the effects of donepezil and galantamine in patients with mild to moderate Alzheimer's disease

Abstract: Objectives To compare directly, in the same patient cohort, the ease of use and tolerability of donepezil and galantamine in the treatment of Alzheimer's disease (AD), and investigate the effects of both treatments on cognition and activities of daily living (ADL). Methods Patients with mild to moderate AD from 14 European centres were randomised to receive open-label donepezil (up to 10 mg once daily) or galantamine (up to 12 mg twice daily) for 12 weeks, according to the approved product labelling. Physicians and caregivers completed questionnaires rating satisfaction with treatment/ease of use in daily practice. Secondary assessments were the ADAS-cog, the MMSE, and the DAD scale to assess ADL. Tolerability was evaluated by reporting adverse events (AEs). Results Both physicians and caregivers reported significantly greater overall satisfaction/ease of use for donepezil (n = 64) compared with galantamine (n = 56) at weeks 4, 12, and endpoint (week 12 LOCF; all p-values <0.05). Significantly greater improvements in cognition were also observed for donepezil versus galantamine on the ADAS-cog at Week 12 and endpoint (p-values <0.05). ADL improved significantly in the donepezil group compared with the galantamine group at weeks 4, 12, and endpoint (p-values <0.05). Most AEs were mild to moderate, however, 46% galantamine-treated patients reported gastrointestinal AEs vs 25% donepezil patients. Conclusions Physician and caregiver ease of use/satisfaction scores, and assessments of cognition and ADL, showed significant benefits for donepezil compared with galantamine in this direct comparative trial. Both treatments were well tolerated, with more gastrointestinal AEs reported for galantamine vs donepezil. Copyright © 2004 John Wiley & Sons, Ltd.

Effect of combined support for people with dementia and carers versus regular day care on behaviour and mood of persons with dementia: results from a multi-centre implementation study.

Abstract: Background A previous study in Amsterdam showed that combined family support in the Meeting Centres Support Programme, in which dementia patients and their carers are both supported by one professional staff member, is more effective in influencing behaviour problems and mood of dementia patients living in the community than non-integrated support, such as day care only. Objective A multi-centre implementation study tests if similar effects are achieved in other regions of The Netherlands. Methods A pretest–posttest control group design was applied. 112 dementia patients who visited psychogeriatric day care in eight community centres across the country and in three nursing homes, and their carers participated in the study. The patients in the experimental group (n = 89) received support from the Meeting Centres Support Programme together with their carers, while the control group (n = 23) received day care only. Behaviour problems (agressive behaviour, inactivity, non-social behaviour) and mood (dissatisfaction, depressive behaviour) were assessed using standardized observation scales. Quality of life was assessed by interviewing the patients. Results After 7 months the Meeting Centres Support Programme, compared to regular day care, showed a moderately positive effect on the degree of total behaviour problems (effect size = 0.52), especially on inactivity (effect size = 0.37) and non-social behaviour (effect size = 0.60), a large effect on depressive behaviour (effect size = 0.92) and a moderate effect on self-esteem (effect size = 0.43). Conclusions The Meeting Centres Support Programme proves to be more effective than regular day care in influencing behaviour problems, especially inactivity and non-social behaviour, and depressed mood. Participation in the programme also seems to have a positive effect on self-esteem, an important aspect of quality of life. These findings surpass the results of the Amsterdam study and confirm the surplus value of the combined family support in the Meeting Centres Support Programme as compared to regular day care for people with mild to severe dementia. Copyright © 2004 John Wiley & Sons, Ltd.

Efficacy and tolerability of venlafaxine in geriatric outpatients with major depression: a double-blind, randomised 6-month comparative trial with citalopram.

Abstract: BACKGROUND: The objectives of the study were to compare efficacy and tolerability of venlafaxine ER 75-150 mg/day with that of citalopram 10-20 mg/day in elderly patients with major depression according to DSM-IV criteria. METHODS: A randomised, double-blind, parallel group 6-month study. Efficacy was assessed by MADRS, CGI Global Improvement, CGI Severity of Illness and GDS-20 scores and safety by physical examinations, vital signs, adverse events and UKU side effect rating. Plasma levels of venlafaxine, its major metabolite O-desmethylvenlafaxine and citalopram were followed. RESULTS: One hundred and fifty-one male and female patients (64-89 years) were enrolled and 118 patients completed the study. Comparable improvements in MADRS, CGI Severity of Illness, CGI Global Improvement and GDS-20 were observed during venlafaxine and citalopram treatment. The MADRS remission rate was 19% for venlafaxine and 23% for citalopram. Side effects were common during both treatments but differed in tremor being more common during citalopram and nausea/vomiting during venlafaxine treatment. There were no clinically significant changes in blood pressure or body weight. CONCLUSION: The observed benefits of venlafaxine treatment in elderly patients with major depression were similar to those observed in younger adults as were reported adverse events and side effects. Treatment with venlafaxine ER was well tolerated and induced beneficial effects of similar magnitude as those of citalopram.

A comparison of side effects of selective serotonin reuptake inhibitors and tricyclic antidepressants in older depressed patients: a meta-analysis.

Abstract: Objective To examine the relative tolerability and side effect profile of tricyclic antidepressants and selective serotonin reuptake inhibitors in older depressed people. Methods A systematic literature search generated 37 randomised controlled trials of TCAs and SSRIs of which 11 were entered into a meta analysis comparing withdrawal rates and side effect profiles. Results 537 TCA recipients and 554 SSRI recipients were compared. TCAs had an increased withdrawal rate (RR: 0.24, CI 1.04, 1.47). A similar result was found when comparing classical TCAs (451 patients) (amitriptyline, clomipramine, doxepin and dothiepin) with SSRIs (466 patients) (RR 1.30 CI: 1.02,1.64). These findings were reflected in the increased TCA prevalence of side effects including dry mouth, drowsiness, dizziness and lethargy. No differences were found when comparing TCA related drugs (mianserin and trazadone) with SSRIs (RR 1.07 CI 0.43, 2.70). Conclusions Despite the relative low prevalence of side effects associated with SSRIs a significant minority of older people find these drugs intolerable and experience nausea, vomiting, dizziness and drowsiness. We conclude that TCA related drugs are comparable to SSRIs in terms of tolerability and may offer an alternative when SSRIs are either contra-indicated or clinically unacceptable. Copyright © 2004 John Wiley & Sons, Ltd.

Dementia, pain, depression, behavioral disturbances, and ADLs: toward a comprehensive conceptualization of quality of life in long-term care.

Abstract: SUMMARY Objectives Quality of life in long-term care settings is a multidimensional construct that includes functional, cognitive, behavioral, and psychological variables. Quality of life variables have been found to be related to one another, but directional influences have not been tested. Methods The purpose of this study was to develop and compare two competing path models composed of quality of life variables, including dementia, pain, behavioral disturbances, and ADLs. Results Path analytic results revealed that cognitive, emotional, and behavioral variables interact with one another to predict patients’ activities of daily living. Pain levels did not influence activities of daily living directly, but rather influenced behavioral disturbances and depression, which in turn influenced activities of daily living. Conclusions These preliminary findings suggest that in order to assist long-term care residents in improving their activities of daily living, decreasing pain is likely to yield the greatest overall improvements. Future research on the relationships between quality of life variables is recommended to further develop multidimensional treatment models for healthcare providers in long-term care. Copyright # 2004 John Wiley & Sons, Ltd. Variables composing quality of life are routinely assessed in long-term care settings in order to track the status of the resident and the effectiveness of care.

A comparison of the effects of Snoezelen and reminiscence therapy on the agitated behaviour of patients with dementia.

Abstract: Background Behavioural disturbance, such as agitation, is a common feature of dementia, and causes significant problems and distress for carers. Snoezelen is increasingly used with people who have dementia, but there is limited evidence of its efficacy. Objective This crossover randomised controlled study aimed to evaluate the effect of Snoezelen on the mood and behaviour of patients with dementia, in comparison to the effect of an established and accepted intervention, reminiscence therapy. Methods Twenty patients with dementia and significant agitated behaviour, received three sessions each of Snoezelen and reminiscence. The effects were assessed using measures of observed agitated behaviour and heart rate over the course of the sessions, and mood and behaviour during the sessions. Results Both interventions had a positive effect. Snoezelen was no more beneficial than reminiscence in terms of effecting a significant reduction in agitated behaviour or heart rate. There was considerable variation in the way individuals responded to each intervention. Snoezelen may have a more positive effect than reminiscence, but due to the observed differences between the interventions being small, and the small number of subjects, this advantage was not demonstrated statistically. Conclusions Further research, with larger numbers of subjects, and an appropriate control is required to establish the benefits of Snoezelen for people at different stages of dementia, and to identify any benefits additional to those derived from increased staff attention. Copyright © 2004 John Wiley & Sons, Ltd.