Research Article
Cost of informal care for community-dwelling mild–moderate dementia patients in a developed Southeast Asian country
- Mei Sian Chong, Woan Shin Tan, Mark Chan, Wee Shiong Lim, Noorhazlina Ali, Yue Ying Ang, Kia Chong Chua
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- Published online by Cambridge University Press:
- 22 May 2013, pp. 1475-1483
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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.
Neural correlates of the components of the clock drawing test
- Teruyuki Matsuoka, Jin Narumoto, Aiko Okamura, Shogo Taniguchi, Yuka Kato, Keisuke Shibata, Kaeko Nakamura, Chio Okuyama, Kei Yamada, Kenji Fukui
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- Published online by Cambridge University Press:
- 16 May 2013, pp. 1317-1323
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Background: The aim of this study was to identify the neural correlates of each component of the clock drawing test (CDT) in drug-naïve patients with Alzheimer's disease (AD) using single photon emission computed tomography.
Methods: The participants were 95 drug-naïve patients with AD. The Rouleau CDT was used to score the clock drawings. The score for the Rouleau CDT (R total) is separated into three components: the scores for the clock face (R1), the numbers (R2), and the hands (R3). A multiple regression analysis was performed to examine the relationship of each score (i.e. R total, R1, R2, and R3) with regional cerebral blood flow (rCBF). Age, gender, and education were included as covariates. The statistical threshold was set to a family-wise error (FWE)-corrected p value of 0.05 at the voxel level.
Results: The R total score was positively correlated with rCBF in the bilateral parietal and posterior temporal lobes and the right middle frontal gyrus. R1 was not significantly positively correlated with rCBF, R2 was significantly positively correlated with rCBF in the right posterior temporal lobe and the left posterior middle temporal lobe, and R3 was significantly positively correlated with rCBF in the bilateral parietal lobes, the right posterior temporal lobe, the right middle frontal gyrus, and the right occipital lobe.
Conclusions: Various brain regions were associated with each component of the CDT. These results suggest that an assessment of these components is useful for the detection of localization of brain damage.
The Tasmanian Healthy Brain Project (THBP): a prospective longitudinal examination of the effect of university-level education in older adults in preventing age-related cognitive decline and reducing the risk of dementia
- Mathew J. Summers, Nichole L.J. Saunders, Michael J. Valenzuela, Jeffery J. Summers, Karen Ritchie, Andrew Robinson, James C. Vickers
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- Published online by Cambridge University Press:
- 25 March 2013, pp. 1145-1155
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Background: Differences in the level of cognitive compromise between individuals following brain injury are thought to arise from underlying differences in cognitive reserve. The level of cognitive reserve attained by an individual is influenced by both genetic and life experience factors such as educational attainment and occupational history. The Tasmanian Healthy Brain Project (THBP) is a world-first prospective study examining the capacity of university-level education to enhance cognitive reserve in older adults and subsequently reduce age-related cognitive decline and risk for neurodegenerative disease.
Methods: Up to 1,000 adults aged 50–79 years at the time of entry into the study will be recruited to participate in the THBP. All participants will be healthy and free of significant medical, psychological, or psychiatric illness. Of the participant sample, 90% will undertake a minimum of 12 months part-time university-level study as an intervention. The remaining 10% will act as a control reference group. Participants will complete an annual comprehensive assessment of neuropsychological function, medical health, socialization, and personal well-being. Premorbid estimates of past cognitive, education, occupational, and physical function will be used to account for the mediating influence of prior life experience on outcomes. Potential contributing genetic factors will also be explored.
Results: Participant results will be assessed annually. Participants displaying evidence of dementia on the comprehensive neuropsychological assessment will be referred to an independent psycho-geriatrician for screening and diagnosis.
Conclusions: The THBP commenced in 2011 and is expected to run for 10–20 years duration. To date, a total of 383 participants have been recruited into the THBP.
Affective functioning after delirium in elderly hip fracture patients
- Chantal J. Slor, Joost Witlox, René W. M. M. Jansen, Dimitrios Adamis, David J. Meagher, Esther Tieken, Alexander P. J. Houdijk, Willem A. van Gool, Piet Eikelenboom, Jos F. M. de Jonghe
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- Published online by Cambridge University Press:
- 30 November 2012, pp. 445-455
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Background: Delirium in elderly patients is associated with various long-term sequelae that include cognitive impairment and affective disturbances, although the latter is understudied.
Methods: For a prospective cohort study of elderly patients undergoing hip fracture surgery, baseline characteristics and affective and cognitive functioning were assessed preoperatively. During hospital admission, presence of delirium was assessed daily. Three months after hospital discharge, affective and global cognitive functioning was evaluated again in patients free from delirium at the time of this follow-up. This study compared baseline characteristics and affective functioning between patients with and without in-hospital delirium. We investigated whether in-hospital delirium is associated with increased anxiety and depressive levels, and post-traumatic stress disorder (PTSD) symptoms three months after discharge.
Results: Among 53 eligible patients, 23 (43.4%) patients experienced in-hospital delirium after hip fracture repair. Patients who had experienced in-hospital delirium showed more depressive symptoms at follow-up after three months compared to the 30 patients without in-hospital delirium. This association persisted in a multivariate model controlling for age, baseline cognition, baseline depressive symptoms, and living situation. The level of anxiety and symptoms of PTSD at follow-up did not differ between both groups.
Conclusion: This study suggests that in-hospital delirium is associated with an increased burden of depressive symptoms three months after discharge in elderly patients who were admitted to the hospital for surgical repair of hip fracture. Symptoms of depression in patients with previous in-hospital delirium cannot be fully explained by persistent (sub)syndromal delirium or baseline cognitive impairment.
Trial name: The Effect of Taurine on Morbidity and Mortality in the Elderly Hip Fracture Patient. URL: http://clinicaltrials.gov/ct2/show/NCT00497978?term=taurine+hip+fracture&rank=1. Registration number: NCT00497978.
Relationship between cortisol level and prevalent/incident cognitive impairment and its moderating factors in older adults
- Olivier Potvin, Hélène Forget, Michel Préville, Djamal Berbiche, Yvon C. Chagnon, Carol Hudon
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- 23 October 2012, pp. 252-262
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Background: The objectives of this study were to examine the factors modifying the relationship between cortisol level and prevalent/incident cognitive impairment in older adults and to verify whether these relationships were non-linear.
Methods: Data were collected from 1,226 individuals aged 65 and older by two in-home interviews separated by 12 months. Cortisol level was measured using saliva samples taken at the beginning of the baseline interview before cognitive, mental, and physical health evaluations. Prevalent and incident cognitive impairment were defined using the Mini-Mental State Examination scores according to normative data for age, education level, and sex.
Results: High morning cortisol level increased the risk of incident cognitive impairment in participants with anxiety or depressive episode while low cortisol level increased the risk in participants without anxiety or depressive episode. In high educated participants, but not in low educated participants, high morning cortisol level was associated with prevalent cognitive impairment and high afternoon cortisol level increased the risk of incident cognitive impairment. The results also suggested that lower morning cortisol values could increase the risk of incident cognitive impairment in individuals with few chronic diseases. A curvilinear relationship was observed between morning cortisol and the probability of incident cognitive impairment, but further analyses suggested that it was likely explained by anxiety and depressive episode.
Conclusions: These results suggest that cognitive impairment in older adults is linked to higher or lower cortisol level depending on characteristics such as anxiety, depressive episode, education level, and physical health.
Establishing the motivations of patients with dementia and cognitive impairment and their carers in joining a dementia research register (DemReg)
- Cerian Avent, Lisa Curry, Sarah Gregory, Sonia Marquardt, Lauren Pae, Danielle Wilson, Karen Ritchie, Craig W. Ritchie
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- Published online by Cambridge University Press:
- 19 March 2013, pp. 963-971
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Background: Connecting willing patients with dementia to suitable clinical research studies has been historically challenging. The United Kingdom Dementia and Neurodegenerative Research Network (DeNDRoN) was established to link patients into high-quality studies. One component is DemReg, a register of dementia patients and their carers who have agreed to be approached regarding future research studies. The limited literature highlights the predominance of altruism mediating research register participation. The objective of this study was to understand the motivations of patients and carers to participate in DemReg.
Methods: There were 107 participants in the study, interviewed using a questionnaire to determine which factors were important in their decision to be on the register. The study compared the proportion of the altruistic motivations articulated with the proportion of the other answers offered.
Results: The two most important motivators for registering on DemReg were to help others (44%; p < 0.001) or themselves (29%; p < 0.001) and altruistic motives took precedence over those for personal benefit. Participants were not motivated by the prospect of payment or by concern that they would be letting down their clinician if they did not register.
Conclusions: There are currently major projects within the United Kingdom to increase the number of patients on dementia registers and to further involvement in dementia research. This study, to the best of our knowledge, is the first to assess the motivations of patients and carers for joining a dementia research register in the United Kingdom, and the findings highlight the importance of altruistic motives.
Familiarity, knowledge, and preferences of family physicians regarding mild cognitive impairment
- Perla Werner, Jeremia Heinik, Eliezer Kitai
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- Published online by Cambridge University Press:
- 25 January 2013, pp. 805-813
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Background: Mild cognitive impairment (MCI) is a common condition among elderly persons. Its early identification is important because MCI can be a precursor of dementia. Since physicians’ knowledge and preferences regarding MCI can be critical in its identification, this study assessed family physicians’ familiarity, knowledge, and preferences regarding help-seeking, diagnosis, and treatment options for MCI.
Method: A convenience sample of 197 family physicians working in one of the largest Health Maintenance Organizations (HMOs) in Israel completed a structured questionnaire. Familiarity, knowledge, and preferences regarding diagnosis, help-seeking, and treatment of MCI were assessed.
Results: The majority of the participants had heard about MCI but a third of those familiar with the term reported knowing almost nothing about it. Participants’ objective knowledge was good regarding several causes of MCI, but 70% reported it to be caused by normal aging. Help-seeking and treatment preferences corresponded with the literature on MCI.
Conclusion: Our findings stress the need to broaden the understanding of primary care physicians’ knowledge and preferences regarding MCI. This research can guide in developing continuous education programs to strengthen areas and groups of physicians reporting low knowledge.
Improving the end-of-life for people with dementia living in a care home: an intervention study
- Gill Livingston, Elanor Lewis-Holmes, Catherine Pitfield, Monica Manela, Diana Chan, Eleanor Constant, Hannah Jacobs, Gaby Wills, Natasha Carson, Jackie Morris
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- Published online by Cambridge University Press:
- 07 August 2013, pp. 1849-1858
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Background:
One in three adults, most of whom are living in a care home at the time, dies with dementia. Their end-of-life is often in hospital, where they may experience uncomfortable interventions without known benefit and die rapidly with uncontrolled pain and comfort needs. This study aimed to improve end-of-life care for people with dementia in a care home by increasing the number and implementation of advanced care wishes.
Methods:We recruited staff, residents with dementia, and their relatives from a 120-bed nursing home in London, UK. The intervention was a ten-session manualized, interactive staff training program. We compared advance care wishes documentation and implementation, place of death for residents who died, and themes from staff and family carers’ after-death interviews pre- and post-intervention.
Results:Post-intervention there were significant increases in documented advance care wishes arising from residents’ and relatives’ discussions with staff about end-of-life. These included do not resuscitate orders (16/22, 73% vs. 4/28, 14%; p < 0.001); and dying in the care homes as opposed to hospital (22/29, 76% vs. 14/30, 47%; p < 0.02). Bereaved relatives overall satisfaction increased from 7.5 (SD = 1.3) pre-intervention to 9.1 (SD = 2.4) post-intervention; t = 17.6, p = 0.06. Relatives reported increased consultation and satisfaction about decisions. Staff members were more confident about end-of-life planning and implementing advanced wishes.
Conclusion:This small non-randomized study is the first end-of-life care in dementia intervention to report an increase in family satisfaction with a reduction in hospital deaths. This is promising but requires further evaluation in diverse care homes.
The Mini-Cog, Clock Drawing Test, and the Mini-Mental State Examination in a German Memory Clinic: specificity of separation dementia from depression
- Monika Milian, Anna-Maria Leiherr, Guido Straten, Stephan Müller, Thomas Leyhe, Gerhard W. Eschweiler
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- 20 August 2012, pp. 96-104
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Background: The aim of this study was to assess the specificities of the Mini-Cog, the Clock Drawing Test (CDT), and the Mini-Mental State Examination (MMSE) against depression and healthy controls in a German Memory Clinic. Furthermore, we analyzed the specificities of all three screening instruments in dependence of actual depression severity.
Methods: Data from 142 depressed elderly, 438 dementia patients, and 64 healthy controls were retrospectively analyzed. The CDT and an extraction of the three-item recall of the MMSE were used to constitute the Mini-Cog algorithm. Depression severity was rated by either the Beck Depression Inventory (BDI) or the Geriatric Depression Scale (GDS) depending on the age of the patients.
Results: The Mini-Cog achieved a specificity of 79.6% against depressed elderly and 100.0% against healthy subjects (p < 0.001). Similarly, the specificities of the CDT (83.8%) and MMSE (92.3% at a cut-off ≤24 and 90.8% at ≤25, respectively) against healthy subjects were significantly higher than the specificities against depressed patients (each p < 0.05). Concerning the depressed patients, the MMSE demonstrated significant higher specificity than the Mini-Cog and the CDT, but also showed the lowest sensitivity for the detection of dementia. Surprisingly, the depression severity had no effect on the specificity of the Mini-Cog and the CDT, only the MMSE was susceptible for the depression severity.
Conclusion: Although the MMSE showed higher specificities, the weighting between the sensitivities and specificities in all tests prove again the Mini-Cog as a short, valid, and sensitive screening tool.
Corrigendum
Speech and orofacial apraxias in Alzheimer's disease – CORRIGENDUM
- Maysa Luchesi Cera, Karin Zazo Ortiz, Paulo Henrique Ferreira Bertolucci, Thaís Soares Cianciarullo Minett
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- Published online by Cambridge University Press:
- 08 July 2013, p. 1686
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Research Article
Relationship between delirium and behavioral symptoms of dementia
- Philippe Landreville, Philippe Voyer, Pierre-Hugues Carmichael
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- 20 December 2012, pp. 635-643
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Background: Persons with dementia frequently present behavioral and psychological symptoms as well as delirium. However, the association between these has received little attention from researchers and current knowledge in this area is limited. The purpose of this study was to examine the relation between delirium and behavioral symptoms of dementia (BSD).
Methods: Participants were 155 persons with a diagnosis of dementia, 109 (70.3%) of whom were found delirious according to the Confusion Assessment Method. BSD were assessed using the Nursing Home Behavior Problem Scale.
Results: Participants with delirium presented significantly more BSD than participants without delirium. More specifically, they presented more wandering/trying to leave, sleep problems, and irrational behavior after controlling for cognitive problems and use of antipsychotics and benzodiazepines. Most relationships between participant characteristics and BSD did not differ according to the presence or absence of delirium, but some variables, notably sleep problems, were more strongly associated to BSD in persons with delirium.
Conclusions: Although correlates of BSD in persons with delirium superimposed on dementia are generally similar to those in persons with dementia alone, delirium is associated with a higher level of BSD. Results of this study have practical implications for the detection of delirium superimposed on dementia, the management of behavioral disturbances in patients with delirium, and caregiver burden.
Membership and management: structures of inter-professional working in community mental health teams for older people in England
- Mark Wilberforce, Sue Tucker, Michele Abendstern, Christian Brand, Clarissa Marie Giebel, David Challis
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- Published online by Cambridge University Press:
- 04 June 2013, pp. 1485-1492
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Background:
Community mental health services are regarded as the preferred first tier of specialist psychogeriatric support, with integrated multidisciplinary teams believed to offer improved decision-making and greater continuity of care than separate single-profession services. In England over 400 community mental health teams (CMHTs) form the cornerstone of such support, yet research has neither assessed progress toward integrating key professional disciplines nor the nature of their membership and management arrangements.
Methods:A self-administered questionnaire was sent to all CMHTs for older people in England, seeking a combination of objective and subjective information on team structure and management.
Results:Responses from 376 (88%) teams highlighted broader multidisciplinary membership than found in a 2004 survey, with particular growth in the number of support workers and other unqualified practitioners. Only modest progress was found in the integration of psychologists and social workers within CMHTs. The data also revealed a trend toward “core” team membership, and away from “sessional” membership in which staff may have divided loyalties between services. Multidisciplinary working was reported as beneficial by many respondents, but examples of “silo working” were also found, which may have hampered service delivery in a minority of teams.
Conclusions:The reported growth in the number of practitioners without professional registration raises issues about the appropriate skill mix and substitution within CMHTs, while local agencies should review barriers to the integration of psychologists and social workers. Further research is required to explore the quality of multidisciplinary team working.
The stages of driving cessation for people with dementia: needs and challenges
- Jacki Liddle, Sally Bennett, Shelley Allen, David C. Lie, Bradene Standen, Nancy A. Pachana
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- Published online by Cambridge University Press:
- 02 September 2013, pp. 2033-2046
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Background:
The impact of dementia on safe driving is well recognized and is generally accepted that all people with dementia are likely to need to cease driving at some stage in the disease process. Both driving and driving cessation can have poor outcomes for people with dementia and their caregivers in terms of health, safety, community access, and well-being. Although approaches to facilitate better outcomes from driving cessation are being developed, the processes of driving cessation for people with dementia are still not fully understood.
Methods:Within a descriptive phenomenological framework, semi-structured interviews were undertaken with key stakeholders, including retired drivers with dementia, family members, and health professionals.
Results:Findings from four retired drivers with dementia, 11 caregivers, and 15 health professionals characterized driving cessation for people with dementia as a process with three stages and associated challenges and needs. The early stage involved worried waiting, balancing safety with impending losses, and the challenge of knowing when to stop. The crisis stage involved risky driving or difficult transportation, acute adjustment to cessation and life without driving, and relationship conflict. The post-cessation stage was described as a long journey with ongoing battles and adjustments as well as decreased life space, and was affected by the disease progression and the exhaustion of caregiver.
Conclusions:The concept of stages of driving cessation for people with dementia could be used to develop new approaches or adapt existing approaches to driving cessation. Interventions would need to be individualized, optimally timed, and address grief, explore realistic alternative community access, and simultaneously maintain key relationships and provide caregiver support.
Cohort differences in dementia recognition and treatment indicators among assisted living residents in Maryland: did a change in the resident assessment tool make a difference?
- Quincy M. Samus, Amrita Vavilikolanu, Lawrence Mayer, Matthew McNabney, Jason Brandt, Constantine G. Lyketsos, Adam Rosenblatt
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- Published online by Cambridge University Press:
- 23 September 2013, pp. 2047-2056
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Background:
There is a lack of empirical evidence about the impact of regulations on dementia care quality in assisted living (AL). We examined cohort differences in dementia recognition and treatment indicators between two cohorts of AL residents with dementia, evaluated prior to and following a dementia-related policy modification to more adequately assess memory and behavioral problems.
Methods:Cross-sectional comparison of two AL resident cohorts was done (Cohort 1 [evaluated 2001–2003] and Cohort 2 [evaluated 2004–2006]) from the Maryland Assisted Living studies. Initial in-person evaluations of residents with dementia (n = 248) were performed from a random sample of 28 AL facilities in Maryland (physician examination, clinical characteristics, and staff and family recognition of dementia included). Adequacy of dementia workup and treatment was rated by an expert consensus panel.
Results:Staff recognition of dementia was better in Cohort 1 than in Cohort 2 (77% vs. 63%, p = 0.011), with no significant differences in family recognition (86% vs. 85%, p = 0.680), or complete treatment ratings (52% vs. 64%, p = 0.060). In adjusted logistic regression, cognitive impairment and neuropsychiatric symptoms correlated with staff recognition; and cognitive impairment correlated with family recognition. Increased age and cognitive impairment reduced odds of having a complete dementia workup. Odds of having complete dementia treatment was reduced by age and having more depressive symptoms. Cohort was not predictive of dementia recognition or treatment indicators in adjusted models.
Conclusions:We noted few cohort differences in dementia care indicators after accounting for covariates, and concluded that rates of dementia recognition and treatment did not appear to change much organically following the policy modifications.
Translation and validation of the 18-item Lubben Social Network Scale with older adults in Mongolia
- Denise Burnette, Sugarmaa Myagmarjav
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- Published online by Cambridge University Press:
- 24 June 2013, pp. 1493-1502
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Background:
In Mongolia, social, demographic, and geographic factors have heightened the need for a reliable means to assess social isolation of older adults. The purpose of this study was to identify, translate, and validate such a measure.
Methods:The study was conducted in two phases: translation and back translation of the 18-item Lubben Social Network Scale to Mongolian (LSNS-18-M) and field testing to establish reliability and validity and to explore potential cut-off points. The sample comprised 198 Mongolians aged ≥55 years selected from six hospitals in Ulaanbaatar, Mongolia.
Results:Internal consistency and intraclass correlations for the LSNS-18-M were excellent, indicating high reliability. The scale showed strong convergence with social disconnectedness and perceived isolation scales and with the Geriatric Depression Scale. It was also inversely related to self-rated health status, but not to the physical or mental health subscales of the Short Form-12 (SF-12) survey. The LSNS-18-M scores discriminated among three levels of social disconnectedness and three levels of perceived isolation. Regarding content validity, the 18 items loaded cleanly on the same three factors as the original LSNS-18, inter-factor correlations were good, all factors were correlated with the LSNS-18-M, and they accounted for two-thirds of variance in scores.
Conclusions:The LSNS-18-M had excellent reliability and good validity with a sample of older Mongolians and should be useful for screening, assessment, and monitoring social isolation. Future studies should examine lack of association with the SF-12 and should assess the scale's use with non-hospitalized and non-urban older adults in Mongolia and with Mongolian speakers outside the country.
Smell identification function as a severity and progression marker in Alzheimer's disease
- Latha Velayudhan, Megan Pritchard, John F. Powell, Petroula Proitsi, Simon Lovestone
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- 19 April 2013, pp. 1157-1166
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Background: Olfactory dysfunction, impaired smell identification in particular, is known as a diagnostic and a marker of conversion in Alzheimer's disease (AD). We aimed to evaluate the associations of olfactory identification impairments with cognition, illness severity, and progression in AD patients.
Methods: Fifty-seven outpatients with late onset mild to moderate AD and 24 elderly non-demented controls (NDC) were assessed, at baseline and after three months, for Mini-Mental State Examination (MMSE), University of Pennsylvania Smell Identification Test (UPSIT), and Bristol Activities of Daily Living and Neuropsychiatry Inventory. AD participants were classified as Rapid Cognitive Decliners (RCD) defined on a priori with a loss of ≥2 points in MMSE within the previous six months.
Results: AD participants had lower olfactory scores than NDC. RCD had lower olfaction scores compared with Non-Rapid Cognitive Decliners (NRCD). Although the baseline UPSIT scores were associated with baseline MMSE scores, it did not interact significantly with change in MMSE over the follow-up period. Using a median split for olfactory scores, the AD participants were classified as Rapid Olfactory Progressors (ROP) (UPSIT ≤ 15) and Slow Olfactory Progressors correlating significantly with RCD/NRCD groups. The ROP group with higher olfactory impairment indicated more symptomatic illness or severity, i.e. lower cognition, higher functional dependence, and presence of behavioral symptoms.
Conclusions: Our study supports association of smell identification function with cognition and its utility as an adjunct clinical measure to assess severity in AD. Further work, including larger longitudinal studies, is needed to explore its value in predicting AD progression.
Patterns of dietary intake and psychological distress in older Australians: benefits not just from a Mediterranean diet
- Allison Hodge, Osvaldo P. Almeida, Dallas R. English, Graham G. Giles, Leon Flicker
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- 03 December 2012, pp. 456-466
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Background: Anxiety and depression contribute to morbidity in elderly adults and may be associated with diet. We investigated the association between diet and psychological distress as a marker for depression.
Methods: Dietary patterns were defined by factor analysis or the Mediterranean Diet Score (MDS); depression and anxiety were assessed 12 years later. A total of 8,660 generally healthy men and women born in Australia and aged 50–69 years from the Melbourne Collaborative Cohort Study were included. At baseline (1990–1994), diet (food frequency questionnaire), education, Socio-Economic Indexes for Areas (SEIFA) – Index of Relative Socio-economic Disadvantage, medication use, social engagement, physical activity, smoking status, alcohol use, and health conditions were assessed; at follow-up (2003–2007), psychological distress was assessed using the Kessler Psychological Distress Scale (K10). Logistic regression was used to identify associations between diet and a K10 score ≥20, indicative of psychological distress.
Results: The MDS was inversely associated with psychological distress, with the odds ratio in the top-scoring group relative to the lowest scoring group being 0.72 (95% confidence interval = 0.54–0.95). Stronger adherence to a traditional Australian-style eating pattern was also associated with a lower K10 score at follow-up, with the odds ratio for having a K10 score indicative of psychological distress for the top 20% of adherence to this pattern relative to the lowest being 0.61 (95% confidence interval = 0.40–0.91).
Conclusions: A Mediterranean-style diet was associated with less psychological distress, possibly through provision of a healthy nutrient profile. The Australian dietary pattern, which included some foods high in fat and sugar content along with whole foods, also showed a weak inverse association. Adherence to this pattern may reflect a feeling of belonging to the community associated with less psychological distress.
Reconceptualizing models of delirium education: findings of a Grounded Theory study
- Andrew Teodorczuk, Elizabeta Mukaetova-Ladinska, Sally Corbett, Mark Welfare
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- 20 December 2012, pp. 645-655
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Background: Effectiveness of educational interventions targeted at improving delirium care is limited by implementation barriers. Studying factors which shape learning needs can overcome these knowledge transfer barriers. This in-depth qualitative study explores learning needs of hospital staff relating to care needs of the confused older patients.
Methods: Fifteen research participants from across the healthcare spectrum working within an acute care setting were interviewed. Five focus groups were undertaken with patients, carers, and mental health specialists. A Grounded Theory methodology was adopted and data were analyzed thematically in parallel to collection until theoretical saturation was reached.
Results: Eight categories of practice gap emerged: ownership of the confused patient, negative attitudes, lack of understanding of how frightened the patient is in hospital, carer partnerships, person-centered care, communication, recognition of cognitive impairment and specific clinical needs (e.g. capacity assessments). Conceptually, the learning needs were found to be hierarchically related. Moreover, a vicious circle relating to the core learning needs of ownership, attitudes and patient's fear emerged. A patient with delirium may be frightened in an alien environment and then negatively labeled by staff who subsequently wish for their removal, thereby worsening the patient's fear.
Discussion: These findings reconceptualize delirium education approaches suggesting a need to focus interventions on core level practice gaps. This fresh perspective on education, away from disease-based delirium knowledge toward work-based patient, team and practice knowledge, could lead to more effective educational strategies to improve delirium care.
Treatment fidelity and acceptability of a cognition-focused intervention for older adults with mild cognitive impairment (MCI)
- Mandy R. Vidovich, Nicola T. Lautenschlager, Leon Flicker, Linda Clare, Osvaldo P. Almeida
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- Published online by Cambridge University Press:
- 21 February 2013, pp. 815-823
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Background: Acceptability and fidelity assessments are an integral part of research, although few published trials comment on these processes in detail.
Methods: We designed a randomized controlled trial (RCT) to identify the benefits of a cognition-focused intervention for older adults with mild cognitive impairment. Participants completed a six-item feedback questionnaire identifying level of satisfaction with their allocated intervention; this formed the acceptability assessment. Audio recordings of all sessions were reviewed and systematically assessed and rated for consistency of delivery (fidelity assessment).
Results: Mean attendance (standard deviation) was 8.1 sessions (2.8) for the cognitive activity (CA) group and 8.4 (2.6) for the control general education group. There were no differences between groups regarding clarity and interest, willingness to attend the program in the community and pay a fee. Both groups reported the interventions to be relevant to their needs; however, this was rated more highly by the CA group (p < 0.01). There was high adherence to delivery of program content across both groups, yielding consistency scores above 95%.
Conclusion: This study illustrates a systematic approach to assess acceptability and fidelity. The results show that the intervention was well received and met the needs of all participants. The manualized structure of the sessions facilitated the systematic implementation and reproducibility of the interventions. Acceptability and fidelity assessments have implications for the validity of assumptions made regarding trial outcomes and should therefore be included as standard process in RCTs.
Homocysteine levels and dementia risk in Yoruba and African Americans
- Hugh C. Hendrie, Olusegun Baiyewu, Kathleen A. Lane, Christianna Purnell, Sujuan Gao, Ann Hake, Adesola Ogunniyi, Oye Gureje, Frederick W. Unverzagt, Jill Murrell, Mark A. Deeg, Kathleen Hall
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- Published online by Cambridge University Press:
- 30 July 2013, pp. 1859-1866
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Background:
High levels of homocysteine have been associated with increased risk for dementia although results have been inconsistent. There are no reported studies from the developing world including Africa.
Methods:In this longitudinal study of two community-dwelling cohorts of elderly Yoruba and African Americans, levels of homocysteine, vitamin B12 and folate were measured from blood samples taken in 2001. These levels were compared in two groups, participants who developed incident dementia in the follow-up until 2009 (59 Yoruba and 101 African Americans) and participants who were diagnosed as cognitively normal or in the good performance category at their last follow-up (760 Yoruba and 811 African Americans). Homocysteine levels were divided into quartiles for each site.
Results:After adjusting for age, education, possession of ApoE, smoking, and time of enrollment the higher quartiles of homocysteine were associated with a non-significant increase in dementia risk in the Yoruba (homocysteine quartile 4 vs. 1 OR: 2.19, 95% CI 0.95–5.07, p = 0.066). For the African Americans, there was a similar but non-significant relationship between higher homocysteine levels and dementia risk. There were no significant relationships between levels of vitamin B12 and folate and incident dementia in either site although folate levels were lower and vitamin B12 levers were higher in the Yoruba than in the African Americans.
Conclusions:Increased homocysteine levels were associated with a similar but non-significant increase in dementia risk for both Yoruba and African Americans despite significant differences in folate levels between the two sites.