Background: This study evaluated private family caregiving at the intersection of private migrant home care and public nursing care on the hospitalization of an older patient.

Methods: Seventy-three individuals were interviewed, including older hospitalized patients, their family members, accompanying migrant home care workers, and nursing personnel.

Results: There was no clear consensus concerning the role of family members. Although family members emphasized care management as their main role, the other three groups emphasized that the family members’ mere physical presence was their main role. All four groups identified potential barriers to family caregiving, rather than motives for family caregiving, hence pointing to a potential discrepancy between expected and performed family caregiving roles.

Conclusions: An indication of the lack of clarity concerning family caregiving roles stems from the finding that family members were frequently viewed as unengaged and neglectful, yet at times they were criticized for being overly involved in patient care. Implications for the care of hospitalized older adults are discussed.

Background: Elder mistreatment, social ageism, and human rights are increasingly powerful discourses in positioning older people in society, yet the relationship between them has rarely been subjected to critical investigation. This perceived relationship will have implications for how mistreatment is understood and responded to.

Method: Critical gerontological approach based on narrative and textual analysis.

Results: Reports of public attitudes toward mistreatment suggest that it is thought to be more common than scientific evidence would suggest; however, reporting is much lower than prevalence. While the discourse over mistreatment has tended to focus on interpersonal relationships, ageism has emphasized social attitudes, and human rights have concentrated on relations between the state and the individual.

Conclusions: In this paper, a series of models have been examined which mark a tendency to restrict and then attempt to reintegrate individual, interpersonal, and social levels of analysis. It is concluded that a focus on the processes of transaction across boundaries rather than contents would facilitate both integrative modeling and deeper understanding of the qualities of abusive situations.

Background: The Neuropsychiatric Inventory (NPI) is widely used to assess psychopathology in dementia. The scoring involves ratings of frequency and severity, as well as the calculation of a composite score. It was suggested recently that, due to lower variance, the frequency score might be more sensitive to detect treatment-related change and to discriminate active treatment from placebo than the composite score, particularly in milder forms of the disease.

Methods: Based on data from three randomized controlled trials in patients with mild to moderate dementia, standardized changes were calculated for both frequency and composite scores for two strata of disease severity. The two strata were formed by dichotomizing the sample along the median score of the short cognitive performance test (SKT) battery.

Results: Across all studies and for both severity strata, standardized changes in frequency scores were not consistently larger than those in composite scores and both scores discriminated active treatment from placebo at similar probabilities for type-1 error.

Conclusion: Our findings do not support the notion that there is a difference between frequency score and composite score with respect to their sensitivity to treatment-related change.

Background: We currently use the depression subscale (HADD) of the Hospital Anxiety and Depression Scale (HADS) for depression screening in elderly inpatients. Given recent concerns about the performance of the HADD in this age group, we performed a quality-control study retrospectively comparing HADD with the diagnosis of depression by a psychiatrist. We also studied the effect of dementia on the scale's performance.

Methods: HADS produces two 7-item subscales assessing depression or anxiety. The HADD was administered by a neuropsychologist. As “gold standard” we considered the psychiatrist's diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Patients older than 65 years, assessed by both the HADD and the psychiatrist, with a clinical dementia rating (CDR) score lower than 3, were included. The effect of dementia was assessed by forming three groups according to the CDR score (CDR0–0.5, CDR1, and CDR2). Simple and multiple logistic regression models were applied to predict the psychiatrist's depression diagnosis from HADD scores. Areas under the receiver operating characteristics curve (AUC) were plotted and compared by χ2 tests.

Results: On both univariate and multiple analyses, HADD predicted depression diagnosis but performed poorly (univariate: p = 0.009, AUC = 0.60 (95% confidence interval (CI) = 0.53–0.66); multiple: p = 0.007, AUC = 0.65 (95% CI = 0.58–0.71)), regardless of cognitive status. Because mood could have changed between the two assessments (they occurred at different points of the hospital stay), the multiple analyses were repeated after limiting time interval at 28, 21, and 14 days. No major improvements were noted.

Conclusion: The HADD performed poorly in elderly inpatients regardless of cognitive status. It cannot be recommended in this population for depression screening without further study.

Background: A growing number of studies are attempting to understand how effective cognitive interventions may be for patients with amnestic mild cognitive impairment (aMCI), particularly in relation to their memory problems.

Methods: The present study aimed to explore the benefits of a working memory (WM) training program in aMCI patients. Patients (N = 20) were randomly assigned to two training programs: the experimental group practiced with a verbal WM task, while the active control group conducted educational activities on memory.

Results: Results showed that the aMCI patients completing the WM training obtained specific gains in the task trained with some transfer effects on other WM measures (visuospatial WM) and on processes involved in or related to WM, e.g. fluid intelligence (the Cattell test) and long-term memory. This was not the case for the aMCI control group, who experienced only a very limited improvement.

Conclusion: This pilot study suggests that WM training could be a valuable method for improving cognitive performance in aMCI patients, possibly delaying the onset of Alzheimer's disease.

Background: In mild Alzheimer's disease (AD), a deficit in episodic memory, particularly autobiographical memory, is clearly established. Several recent studies have also shown impaired semantic memory from the onset of the disease. Musical memory capacities may be especially preserved and listening to music might encourage autobiographical recall. The aim of this study was to explore recall of popular songs in AD.

Methods: We tested 12 patients with mild AD and 12 control subjects. We created a tool made up of old French popular songs: POP 10. This tool is a questionnaire composed of several subtests: melodic free recall, chorus free recall, melodic recognition, chorus recognition, semantic knowledge, autobiographical recall about the song, and autobiographical recall about the interpreter.

Results: We used non-parametric tests, the Mann–Whitney test (M–W), the Friedman test, and the a posteriori Wilcoxon test. Results of AD patients were rather similar to those of control participants for melodic memory. Concerning chorus memory (except recognition), semantic knowledge, and autobiographical recall about the interpreter, results of AD patients were significantly weaker than those of control participants. The most important result concerned autobiographical recall about the song: we found no impairment-related differences between the two groups.

Conclusion: Our findings demonstrate that popular songs can be excellent stimuli for reminiscence, such as the ability to produce an autobiographical memory related to a song. Thus, we confirm that musical semantic knowledge associated with a song may be relatively preserved in the early stages of AD. This leads to new possibilities for cognitive stimulation.

Background: Clinical research is required to develop and evaluate suicide prevention interventions in the elderly. However, there is insufficient information available about how to best recruit suicidal older adults for such research. This study evaluated the success and efficiency of five recruitment strategies for a clinical trial on the efficacy of cognitive therapy for suicidal older men.

Methods: For each strategy, the numbers of individuals approached, screened, and enrolled were calculated, and the expenses and time associated with each enrollment estimated. Men who were 60 years or older and who had a desire for suicide over the past month were eligible for the trial.

Results: Of 955 individuals considered for trial, 33 were enrolled. Most enrollments were sourced from the Veterans Affairs Behavioral Health Laboratory. Recruiting form this source was also the most time and cost efficient recruitment strategy in the study.

Conclusions: Recruitment strategies are effective when they are based on collaborative relationships between researchers and providers, and utilize an existing infrastructure for involving patients in ongoing research opportunities.

Background: Exercising choice and control over decisions is central to quality of life. The Mental Capacity Act 2005 (England and Wales) provides a legal framework to safeguard the rights of people with dementia to make their own decisions for as long as possible. The impact of this on long-term planning has been investigated; everyday decision-making in people's own homes remains unexplored.

Methods: Using a phenomenological approach, we interviewed 12 dyads (one person with dementia + one carer) four times over one year to ascertain experience of decision-making, how decisions were negotiated, and how dynamics changed. Qualitative interviews were conducted in people's own homes, and thematic analysis was applied to transcripts.

Results: Respecting autonomy, decision-specificity and best interests underlay most everyday decisions in this sample. Over time, dyads transitioned from supported decision-making, where person with dementia and carer made decisions together, to substituted decision-making, where carers took over much decision-making. Points along this continuum represented carers’ active involvement in retaining their relative's engagement through providing cues, reducing options, using retrospective information, and using the best interests principle. Long-term spouse carers seemed most equipped to make substitute decisions for their spouses; adult children and friend carers struggled with this.

Conclusions: Carers may gradually take on decision-making for people with dementia. This can bring with it added stresses, such as determining their relative's decision-making capacity and weighing up what is in their best interests. Practitioners and support services should provide timely advice to carers and people with dementia around everyday decision-making, and be mindful how abilities may change.

Background: Dementia is a major public health problem in aging populations. The Clinical Dementia Rating (CDR) classifies the severity of dementia and identifies borderline cases that supposedly have higher rates of conversion to dementia. This study aims to verify the dementia conversion rate (CR) in a subsample of an elderly cohort (70+ free of the disease), and to identify risk factors, determining whether CDR is able to predict which individuals have high likelihood of converting.

Methods: A subsample of 156 participants was clinically evaluated for dementia at baseline in which 80 patients without dementia were reassessed after 2.6 years on average to verify the conversion. The CR was analyzed according to demographic, health variables, and CDR classification at baseline, using the Poisson regression method in univariate and multivariate analyses, with exposure time as an offset variable (person-years).

Results: From those re-evaluated, 50% had CDR = 0 and a CR of 38.1/1,000 person-years and the other 50%, CDR = 0.5 (70% with sum of boxes scores ≤1, CR = 145.4/1,000 person-years and 30% > 1, CR = 216.8/1,000 person-years). CR was 91.3/1,000 person-years on average. In the multivariate analysis, when compared with those with CDR = 0, the hazard ratio of those with CDR = 0.5 was 3.82; and for those with CDR = 0.5 and sum of boxes scores >1, 5.69.

Conclusions: Conversion rate to dementia was significantly higher among those with CDR = 0.5 and even higher for those whose sum of boxes scores was >1. Therefore, CDR was able to predict which individuals had a higher likelihood of converting to dementia.

Background: There is suggestion that self-reported depressive syndromes can independently manifest in the general population as cognitive/affective or somatic/vegetative. The Beck Depression Inventory, 2nd edition (BDI-II), a self-report measure of depressive symptoms, has been shown to support this two-factor structure. However, this finding has not been examined in an older adult sample with cognitive impairment. In order to determine whether older adults with cognitive impairments exhibit similarly independent cognitive/affective and somatic/vegetative depressive syndromes, we explored the factor structure of the BDI-II in this population.

Methods: Participants were 228 older adults (mean age = 74, SD = 7.9) diagnosed with mild cognitive impairment (MCI; n = 137) or early Alzheimer's disease (n = 85), who completed the BDI-II as part of an outpatient neuropsychological evaluation. Exploratory principal component factor analysis with direct Oblimin rotation was conducted, and a two-factor solution was specified based on our theoretical conceptualization of the cognitive/affective and somatic/vegetative items from the scale.

Results: The first factor represented cognitive/affective symptoms of depression (e.g. self-dislike, pessimism, worthlessness), and accounted for 36% of the variance. Adding the second factor, reflecting somatic/vegetative items (e.g. sleep and appetite changes, loss of energy), accounted for an additional 6.8% of the variance.

Conclusion: Results supported the presence of two distinct depressive syndromes, cognitive/affective and somatic/vegetative symptoms. Thus, cognitively impaired older adults report mood symptoms relatively similarly to younger and midlife adults. This supports the validity of self-reported mood in this group, and the results may have implications for psychiatric treatment in this population.

Background: Several risk factors for dementia, Alzheimer's disease, and cognitive impairment have been established; however, knowledge about risk factors in the very old population (≥85 years) is limited. This study describes the association of several baseline factors with dementia in participants aged ≥85 years, and investigates factors associated with a higher risk of incident dementia over five years.

Methods: The participants in this population-based cohort study were aged 85, 90, and ≥95 years at baseline (2000–2002). Data were collected during home visits for interviews and testing, from a review of medical records, and/or interviewing the caregiver or next of kin. After five years 212 participants could be followed up concerning incident dementia. Multivariate logistic regression was used.

Results: At baseline, 100/353 (28%) of participants had a dementia diagnosis. Over five years, 71/212 (33.5%) participants developed dementia. Few participants with dementia at baseline remained alive after five years (12%). Depression at the baseline and follow-up time were associated with a higher risk of dementia, odds ratio (OR) (95% CI, p-value) 2.91 (1.37–6.16, 0.005) and 1.61 (1.26–2.05, <0.001) respectively. More social contact and a higher Mini-Mental State Examination score at baseline were associated with lower risk of incident dementia, OR (95% CI, p-value) 0.87 (0.78–0.97, 0.009) and 0.83 (0.74–0.93, 0.001) respectively.

Conclusions: Prevalence and incidence of dementia are high in very old people and dementia appears to be a fatal disorder. Depression is associated with higher risk of incident dementia over five years whereas more frequent social contacts and a higher MMSE score are associated with lower risk.

Background: Difficulty in retrieving people's names is very common in the early stages of Alzheimer's disease and mild cognitive impairment. Such difficulty is often observed as the tip-of-the-tongue (TOT) phenomenon. The main aim of this study was to explore whether a famous people's naming task that elicited the TOT state can be used to discriminate between amnestic mild cognitive impairment (aMCI) patients and normal controls.

Methods: Eighty-four patients with aMCI and 106 normal controls aged over 50 years performed a task involving naming 50 famous people shown in pictures. Univariate and multivariate regression analyses were used to study the relationships between aMCI and semantic and phonological measures in the TOT paradigm.

Results: Univariate regression analyses revealed that all TOT measures significantly predicted aMCI. Multivariate analysis of all these measures correctly classified 70% of controls (specificity) and 71.6% of aMCI patients (sensitivity), with an AUC (area under curve ROC) value of 0.74, but only the phonological measure remained significant. This classification value was similar to that obtained with the Semantic verbal fluency test.

Conclusions: TOTs for proper names may effectively discriminate aMCI patients from normal controls through measures that represent one of the naming processes affected, that is, phonological access.

Background: Although knowledge of established risk factors for Alzheimer's disease (AD) can logically contribute to the search for predictors of the progression of cognitive impairment, it has not yet been firmly established where in the cognitive impairment process these risk factors exert their effects and how to predict quantitatively for the progression of mild cognitive impairments (MCI) to AD. This study aimed to determine whether known risk factors increased the risk of progression from MCI to AD and to make prediction based on transition probabilities.

Methods: Based on ten examinations of 600 community-dwelling MCI residents and cognitive assessments to classify individuals into MCI, global impairment, and AD, a multi-state Markov Cox's regression model was used and the hazard ratios with their confidence intervals and transition probabilities were estimated.

Results: Multivariate analysis showed that gender, age, and hypertension were statistically significant predictors of transition from MCI to global impairment; age, education, and reading statistically influenced transition from global impairment to MCI; gender, age, hypertension, diabetes, and apolipoprotein E geneε4 status were statistically associated with transition from global impairment to AD. Subjects at MCI were more likely (67%) to remain in that cognitive state at the next cognitive assessment than to transition to cognitive deterioration. For global impairment, probability of remaining in the same state was only 18% and that of forward transition was three times more likely than that of backward transition.

Conclusions: Known risk factors influenced differently for different transitions. Transition from global impairment was more likely to worsen to severe cognitive deterioration than transition from MCI.

Background: Cost of informal care constitutes an important component of total dementia care cost. It also reflects resource utilization by patients and caregivers. We aim to quantify the informal cost of care for mild to moderate dementia patients.

Methods: We recruited 165 patient–caregiver dyads with mild to moderate dementia. Informal care burden was assessed using the Resource Utilization in Dementia (RUD)-Lite instrument. A generalized linear model was fitted for association between cost of informal care and cognitive impairment, taking into account patient demographics, disease factors, and use of paid domestic help. Marginal estimates were obtained from the model for the purpose of illustration and discussion.

Results: Total hours of informal care by primary caregiver doubled in moderate dementia patients, with 57.9% having paid domestic help to assist in care. Functional factors and use of paid domestic help were significantly associated with informal care costs. Costs were consistently higher for patients without paid domestic help for mild- and moderate dementia.

Conclusion: This study demonstrates the informal care costs of caring for mild–moderate dementia patients in Singapore, with the unique cost savings provided by live-in paid domestic help, and potentially may aid policy-makers in allocation of resources and support to caregivers.