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This chapter examines Parkinson's disease dementia (PDD), including its epidemiology, aetiology, pathophysiology, clinical features, prognosis, and cognitive profile. Speech-language pathologists (SLPs) are primarily concerned with speech, language, hearing, voice, fluency, and swallowing in adults with neurodegenerative disorders and how each of these functions may be compromised by cognitive impairment. These aspects of communication are addressed at length in the language and communication profile of PDD. Language is examined under the following levels: phonology; morphology and syntax; vocabulary and semantics; and pragmatics and discourse. Speech-language pathologists must assess and treat clients with PDD. The techniques and approaches they employ in their work are addressed under speech-language pathology management.
This chapter examines vascular dementia (VD), including its epidemiology, aetiology, pathophysiology, clinical features, prognosis, and cognitive profile. Speech-language pathologists (SLPs) are primarily concerned with speech, language, hearing, voice, fluency, and swallowing in adults with neurodegenerative disorders and how each of these functions may be compromised by cognitive impairment. These aspects of communication are addressed at length in the language and communication profile of VD. Language is examined under the following levels: phonology; morphology and syntax; vocabulary and semantics; and pragmatics and discourse. Speech-language pathologists must assess and treat clients with VD. The techniques and approaches they employ in their work are addressed under SLP speech-language pathology management.
This chapter examines Alzheimer’s dementia (AD), including its epidemiology, aetiology, pathophysiology, clinical features, prognosis, and cognitive profile. Speech-language pathologists (SLPs) are primarily concerned with speech, language, hearing, voice, fluency, and swallowing in adults with neurodegenerative disorders and how each of these functions may be compromised by cognitive impairment. These aspects of communication are addressed at length in the language and communication profile of Alzheimer's dementia. Language is examined under the following levels: phonology; morphology and syntax; vocabulary and semantics; and pragmatics and discourse. Speech-language pathologists must assess and treat clients with Alzheimer's dementia. The techniques and approaches they employ in their work are addressed under SLP speech-language pathology management.
To develop a staff training intervention for agitation in people with severe dementia, reaching end-of-life, residing in nursing homes (NHs), test feasibility, acceptability, and whether a trial is warranted.
Feasibility study with pre- and post-intervention data collection, qualitative interviews, and focus groups.
Three NHs in South East England with dementia units, diverse in terms of size, ownership status, and location.
Residents with a dementia diagnosis or scoring ≥2 on the Noticeable Problems Checklist, rated as “severe” on Clinical Dementia Rating Scale, family carers, and staff (healthcare assistants and nurses).
Manualized training, delivered by nonclinical psychology graduates focusing on agitation in severe dementia, underpinned by a palliative care framework.
Main outcomes were feasibility of recruitment, data collection, follow-up, and intervention acceptability. We collected resident, family carer, and staff demographics. Staff provided data on resident’s agitation, pain, quality of life, and service receipt. Staff reported their sense of competence in dementia care. Family carers reported on satisfaction with end-of-life care. In qualitative interviews, we explored staff and family carers’ views on the intervention.
The target three NHs participated: 28 (49%) residents, 53 (74%) staff, and 11 (85%) family carers who were eligible to participate consented. Eight-four percent of staff attended ≥3 sessions, and we achieved 93% follow-up. We were able to complete quantitative interviews. Staff and family carers reported the intervention and delivery were acceptable and helpful.
The intervention was feasible and acceptable indicating a larger trial for effectiveness may be warranted.
Post-traumatic stress disorder (PTSD) has been identified as a potential risk factor for developing dementia. There are currently, however, no meta-analyses quantifying this risk.
To systematically review and quantify the risk of future dementia associated with PTSD across populations. PROSPERO registration number CRD42019130392.
We searched nine electronic databases up to 25 October 2019 for longitudinal studies assessing PTSD and risk of dementia. We used random- and fixed-effects meta-analyses to pool estimates across studies.
PTSD was associated with a significant risk for all-cause dementia: pooled hazard ratio HR = 1.61 (95% CI 1.43–1.81, I2= 85.8%, P < 0.001; n = 1 693 678; 8 studies). Pooled HR was 1.61 (95% CI 1.46–1.78; I2= 80.9%, P < 0.001; n = 905 896; 5 studies) in veterans, and 2.11 (95% CI 1.03–4.33, I2= 91.2%, P < 0.001; n = 787 782; 3 studies) in the general population. The association between PTSD and dementia remained significant after excluding studies with high risk of bias (HR = 1.55, 95% CI 1.39–1.73, I2= 83.9%, P < 0.001; n = 1 684 928; 7 studies). Most studies included were retrospective and there was evidence of high heterogeneity.
This is the first meta-analysis quantifying the association of PTSD and risk of dementia showing that PTSD is a strong and potentially modifiable risk factor for all-cause dementia. Future studies investigating potential causal mechanisms, and the protective value of treating PTSD are needed.
This study was aimed to evaluate the effectiveness of a home-based physical exercise program on participants’ mental health: psychological symptoms, depression, and burden of female informal caregivers.
Design and participants:
In a randomized controlled trial, a sample of 48 female informal primary caregivers completed the entire study, 25 were randomly allocated to the intervention group (IG), and 23 participants to the control group (CG).
Participants in the IG performed two 60-minute-long physical exercise sessions per week (36 weeks) that were supervised by a personal trainer at caregivers’ home during 9 months. The CG continued their habitual leisure-time activities.
Subjective burden was assessed by the Zarit Burden Interview. The risk of depression was measured by the Geriatric Depression Scale Short Form 15-item version, and psychological symptoms were evaluated by the Symptom Check List-90-Revised (SCL-90-R). All participants were evaluated at baseline and at the end of the intervention.
A promising positive impact of the intervention on caregivers’ subjective burden and risk of depression was found in the IG. In addition, no significant between-group differences were found in any of nine subscales scores of the SCL-90-R. Finally, care recipients’ level of functional independence and area of residence were found to be predictors of the promising positive impact on caregivers’ subjective burden and risk of depression.
The present home-based physical exercise intervention that was individually implemented has shown promising results to reduce subjective burden and risk of depression in female caregivers of relatives with dementia. However, future research efforts should elucidate both the particular dose of physical exercise and the particular duration of the intervention that are required to obtain the expected significant positive impact. Finally, future inclusion of psychological approaches, besides physical exercise, might help reduce female caregivers’ psychological symptoms.
Autoimmune encephalitis (AE) is an important consideration during the diagnostic work-up of secondary mental disorders. Indeed, isolated psychiatric syndromes have been described in case reports of patients with underlying AE. Therefore, the authors performed a systematic literature review of published cases with AE that have predominant psychiatric/neurocognitive manifestations. The aim of this paper is to present the clinical characteristics of these patients.
The authors conducted a systematic Medline search via Ovid, looking for case reports/series of AEs with antineuronal autoantibodies (Abs) against cell surface/intracellular antigens combined with predominant psychiatric/neurocognitive syndromes. The same was done for patients with Hashimoto encephalopathy/SREAT. Only patients with signs of immunological brain involvement or tumors in their diagnostic investigations or improvement under immunomodulatory drugs were included.
We identified 145 patients with AE mimicking predominant psychiatric/neurocognitive syndromes. Of these cases, 64% were female, and the mean age among all patients was 43.9 (±22.1) years. Most of the patients had Abs against neuronal cell surface antigens (55%), most frequently against the NMDA-receptor (N = 46). Amnestic/dementia-like (39%) and schizophreniform (34%) syndromes were the most frequently reported. Cerebrospinal fluid changes were found in 78%, electroencephalography abnormalities in 61%, and magnetic resonance imaging pathologies in 51% of the patients. Immunomodulatory treatment was performed in 87% of the cases, and 94% of the patients responded to treatment.
Our findings indicate that AEs can mimic predominant psychiatric and neurocognitive disorders, such as schizophreniform psychoses or neurodegenerative dementia, and that affected patients can be treated successfully with immunomodulatory drugs.
Health factors such as diabetes, severe obesity and chronic kidney disease are all associated with a more severe outcome following coronavirus disease 2019 (COVID-19) infection. However, there has been little exploration into the impact of mental and behavioural disorders on outcomes associated with COVID-19. We investigated outcomes for older people who used mental health services. Those who had a COVID-19-associated death had previously rated worse across a range of health and social problems, including mental health related problems. Our findings evidence the need to urgently explore whether mental and behavioural disorders should also be considered a health risk factor for a more severe outcome from COVID-19 infection in older people.
Caring for a person with dementia is associated with poor mental, physical, and social health, which makes it important to consider how carers are best supported in their caring role to preserve both their and the person with dementia’s well-being. At present, a robust instrument to assess carers’ support needs does not exist. This study aimed to develop a self-reported questionnaire to assess the support needs of carers of people with dementia. The objectives were to: (1) generate items, (2) pilot test, and (3) field-test the questionnaire.
Development and field-testing of a new questionnaire.
Primary and secondary health and social care of informal carers and people with dementia in nine municipalities and one dementia clinic in a hospital in Denmark.
Eight experts, 12 carers, and 7 digital users participated in pilot testing. 301 carers participated in field-testing.
Items for inclusion were generated based on interviews and literature review. An iterative process of data collection was applied to establish face and content validity of the Dementia Carer Assessment of Support Needs Tool (DeCANT) using Content Validity Index among experts and cognitive interviews with carers. Field-testing of DeCANT among carers included using the 12-item Short Form Health Survey, the Barthel-20 Index, and the Neuropsychiatric Inventory.
Initially, an item pool of 63 items was generated, and pilot testing reduced this to 42 items. Subsequent field-testing resulted in a 25-item version of DeCANT, and confirmatory factor analysis of three hypothesized models demonstrated a marginally better fit to a four-factor model with fit indices of: χ2 = 775.170 (p < 0.001), root mean square error of approximation = 0.073, Comparative Fit Index = 0.946, the Tucker-Lewis Index = 0.938, and weighted root mean residual (WRMR) = 1.265.
DeCANT is a 25-item carer-reported questionnaire that can be used to help identify their support needs when caring for a person with dementia to enable supportive interventions and improve carers’ health and well-being.
While early diagnosis of younger-onset dementia (YOD) is crucial in terms of accessing appropriate services and future planning, diagnostic delays are common. This study aims to identify predictors of delay to diagnosis in a large sample of people with YOD and to investigate the impact of a specialist YOD service on this time to diagnosis.
A retrospective cross-sectional study.
The inpatient unit of a tertiary neuropsychiatry service in metropolitan Victoria, Australia.
People diagnosed with a YOD.
Measurements and methods:
We investigated the following predictors using general linear modeling: demographics including sex and location, age at onset, dementia type, cognition, psychiatric diagnosis, and number of services consulted with prior to diagnosis.
A total of 242 inpatients were included. The mean time to diagnosis was 3.4 years. Significant predictors of delay included younger age at onset, dementia type other than Alzheimer’s disease (AD) and behavioral-variant frontotemporal dementia (bvFTD), and increased number of services consulted. These predictors individually led to an increased diagnostic delay of approximately 19 days, 5 months, and 6 months, respectively. A specialized YOD service reduced time to diagnosis by 12 months.
We found that younger age at onset, having a dementia which was not the most commonly occurring AD or bvFTD, and increasing number of services were significant predictors of diagnostic delay. A novel result was that a specialist YOD service may decrease diagnostic delay, highlighting the importance of such as service in reducing time to diagnosis as well as providing post-diagnostic support.
Due to the nature of Alzheimer's disease (AD), health technology assessment (HTA) agencies might face considerable challenges in choosing appropriate outcomes and outcome measures for drugs that treat the condition. This study sought to understand which outcomes informed previous HTAs, to explore possible reasons for prioritizations, and derive potential implications for future assessments of AD drugs.
We conducted a literature review of studies that analyzed decisions made in HTAs (across disease areas) in three European countries: England, Germany, and The Netherlands. We then conducted case studies of technology assessments conducted for AD drugs in these countries.
Overall, outcomes measured using clinical scales dominated decisions or recommendations about whether to fund AD drugs, or price negotiations. HTA processes did not always allow the inclusion of outcomes relevant to people with AD, their carers, and families. Processes did not include early discussion and agreement on what would constitute appropriate outcome measures and cut-off points for effects.
We conclude that in order to ensure that future AD drugs are valued appropriately and timely, early agreement with various stakeholders about outcomes, outcome measures, and cut-offs is important.
Recently published diagnostic criteria for mild cognitive impairment with Lewy bodies (MCI-LB) include five neuropsychiatric supportive features (non-visual hallucinations, systematised delusions, apathy, anxiety and depression). We have previously demonstrated that the presence of two or more of these symptoms differentiates MCI-LB from MCI due to Alzheimer's disease (MCI-AD) with a likelihood ratio >4. The aim of this study was to replicate the findings in an independent cohort.
Participants ⩾60 years old with MCI were recruited. Each participant had a detailed clinical, cognitive and imaging assessment including FP-CIT SPECT and cardiac MIBG. The presence of neuropsychiatric supportive symptoms was determined using the Neuropsychiatric Inventory (NPI). Participants were classified as MCI-AD, possible MCI-LB and probable MCI-LB based on current diagnostic criteria. Participants with possible MCI-LB were excluded from further analysis.
Probable MCI-LB (n = 28) had higher NPI total and distress scores than MCI-AD (n = 30). In total, 59% of MCI-LB had two or more neuropsychiatric supportive symptoms compared with 9% of MCI-AD (likelihood ratio 6.5, p < 0.001). MCI-LB participants also had a significantly greater delayed recall and a lower Trails A:Trails B ratio than MCI-AD.
MCI-LB is associated with significantly greater neuropsychiatric symptoms than MCI-AD. The presence of two or more neuropsychiatric supportive symptoms as defined by MCI-LB diagnostic criteria is highly specific and moderately sensitive for a diagnosis of MCI-LB. The cognitive profile of MCI-LB differs from MCI-AD, with greater executive and lesser memory impairment, but these differences are not sufficient to differentiate MCI-LB from MCI-AD.
Currently, no separate service exists for patients with young-onset dementia in Cambridgeshire. These patients are managed together with late-onset dementia patients within old age psychiatry services. To inform service design, we sought to characterise young-onset dementia patients in our population. We first analysed service-level data and supplemented this with a detailed case review of 90 patients.
Young-onset dementia remains a relatively rare condition. Only a small proportion of those referred for assessment receive a diagnosis of dementia. Data collected on presenting complaints, comorbidities, medication and Health of the Nation Outcome Scales scores associated young-onset dementia with a greater incidence of depression than late-onset dementia. Outcomes in the two groups did not appear to differ.
The data presented here do not suggest a need to create a separate service. Practitioners should be aware of the increased incidence of depression observed in this group.
The aim of the study was to identify components of the COM-B (capability, opportunity, motivation and behaviour) model that influences behaviour to modify dietary patterns in 40–55-year-olds living in the UK, in order to influence the risk of cognitive decline in later life.
This is a qualitative study using the COM-B model and theoretical domains framework (TDF) to explore beliefs to adopting the Mediterranean-DASH Intervention for Neurodegenerative delay (MIND) diet.
Twenty-five participants were recruited onto the study to take part in either a focus group or an interview. Participants were men and women aged between 40 and 55 years. Participants were recruited via email, Facebook and face to face.
Content analysis revealed that the main perceived barriers to the adoption of the MIND diet were time, work environment, taste preference and convenience. The main perceived facilitators reported were improved health, memory, planning and organisation, and access to good quality food.
This study provides insight into the personal, social and environmental factors that participants report as barriers and facilitators to the adoption of the MIND diet among middle-aged adults living in the UK. More barriers to healthy dietary change were found than facilitators. Future interventions that increase capability, opportunity and motivation may be beneficial. The results from this study will be used to design a behaviour change intervention using the subsequent steps from the Behaviour Change Wheel.
Dementia is recognised as the biggest health crisis of our time in terms of high personal and social costs and wider impact on health and social care systems. Increases in people living with dementia and multi-morbidities presents critical challenges for home care worldwide. Health-care systems struggle to provide adequate home-care services, delivering limited care restricted to a single-condition focus. This study explored the experiences and expectations of home care from the multiple perspectives of people living with dementia and multi-morbidities and home-care workers providing support. Findings draw from qualititative semi-structured interviews with people with dementia (N = 2), their partners (N = 2), other partners or family carers (N = 6) and home-care workers (N = 26). Three themes are identified: (a) the preference for and value of home; (b) inadequate home-care provision and enhanced care burden; and (c) limited training and education. Despite continued calls for home-care investment, the focus on reduction in costs hides key questions and further dialogue is required exploring how people with dementia can be supported to live independently and flourish at home. This study considers these complex experiences and care requirements through the prism of disability and human rights frameworks. This paper concludes with consideration of more recent human social rights debate. We discuss critically what this may mean for people living with dementia and consider the implications for co-requisite policy development to optimise available home-care support.
The incidence of dementia in Black, Asian and minority ethnic (BAME) groups is increasing in the UK, with concern about underdiagnosis and late presentation.
By reviewing referrals to memory clinics from Leicester City we examined whether the following differed by ethnicity: the proportion with a diagnosis of dementia, type of dementia and severity at presentation.
We examined referrals between 2010 and 2017: all those whose ethnicity was recorded as Black (n = 131) and a random sample of 260 Asian and 259 White British referrals. Severity of dementia was assessed by record review. Odds ratios (ORs) were adjusted for general practice, age, gender and year of referral.
A diagnosis of dementia was recorded in 193 (74.5%) White British, 96 (73.3%) Black and 160 (61.5%) Asian referrals. Compared with Asians, White British had twice the adjusted odds of a dementia diagnosis (OR = 1.99 (1.23–3.22). Of those with dementia, Alzheimer's disease was more common in White British (57.0%) than in Asian (43.8%) and Black referrals (51.0%): adjusted OR White British versus Asian 1.76 (1.11–2.77). Of those with dementia, the proportion with moderate/severe disease was highest in White British (66.8%), compared with 61.9% in Asian and 45.8% in Black groups. The adjusted OR for the White versus Black groups was 2.03 (1.10–3.72), with no significant difference between Asian and White British groups.
Differences in confirmed dementia suggest general practitioners have a lower threshold for referral for possible dementia in some BAME groups. Unlike other centres, we found no evidence of greater severity at presentation in Asian and Black groups.
The prevalence of dementia is rising in low-resource countries, where specialist memory services are almost non-existent. The COVID-19 pandemic has created opportunities for innovative remote healthcare. Research shows a lack of dementia literacy and help-seeking behaviour for memory-related problems among older adults in South Asian countries. This paper proposes a remote memory service model and virtual dementia training in South Asian countries, called Memory First Aid (MFA). MFA offers help to a person experiencing memory difficulties until appropriate professional help is received. The MFA course is a 12-h webinar-based package consisting of four weekly modules. It covers dementia awareness and clinical features. The aim is to develop a non-medical workforce able to screen and assess older people with suspected dementia.
COVID-19 pandemic in Argentina has affected the care of older adults with dementia deeply. Our objective was to study how the obligatory social isolation affected stress caregiver and burden of care of family members of subjects living with dementia in the community after the initial 4 weeks of quarantine in our setting. We did a questionnaire survey among 80 family caregivers of persons with Alzheimer’s disease (AD) or related dementia collected on April 2020. We designed a visual analog scale to test the level of the burden of care. Characteristics of people with dementia and their caregivers were analyzed with descriptive (mean, standard deviation, frequency and percent) and inferential statistics (chi-square test). The sample included older adults (mean age: 80.51 ± 7.65) with different stages of dementia. Family was the primary provider of care in 65%. Overall, COVID-19 confinement increased stress caregiver independently of the dementia stage, but those caring for severe cases had more stress compared to milder forms of the disease. Other findings were that half of the subjects with dementia experienced increased anxiety and that most family members discontinued all sort of cognitive and physical therapies. Family members’ main concerns were for severe dementia cases, fear of absence of the paid caregiver during the epidemic, and for mild cases fear of spreading the disease while assisting patients with instrumental activities. A partnership between departments of public health, care workers and families must be planned to guarantee continuity of care during these unique COVID-19 times.
The efficacy of acetylcholinesterase inhibitors and memantine in the symptomatic treatment of Alzheimer's disease is well-established. Randomised trials have shown them to be associated with a reduction in the rate of cognitive decline.
To investigate the real-world effectiveness of acetylcholinesterase inhibitors and memantine for dementia-causing diseases in the largest UK observational secondary care service data-set to date.
We extracted mentions of relevant medications and cognitive testing (Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores) from de-identified patient records from two National Health Service (NHS) trusts. The 10-year changes in cognitive performance were modelled using a combination of generalised additive and linear mixed-effects modelling.
The initial decline in MMSE and MoCA scores occurs approximately 2 years before medication is initiated. Medication prescription stabilises cognitive performance for the ensuing 2–5 months. The effect is boosted in more cognitively impaired cases at the point of medication prescription and attenuated in those taking antipsychotics. Importantly, patients who are switched between agents at least once do not experience any beneficial cognitive effect from pharmacological treatment.
This study presents one of the largest real-world examination of the efficacy of acetylcholinesterase inhibitors and memantine for symptomatic treatment of dementia. We found evidence that 68% of individuals respond to treatment with a period of cognitive stabilisation before continuing their decline at the pre-treatment rate.
For many years, dementia care has been dominated by the standard medical approach, in which dementia is treated mainly with drugs, such as anti-anxiety, antidepressant and anti-psychotic medications. With the aim of seeking effective treatments for patients with dementia, over the last years, several contributions have criticised the pervasive use of drugs for the management of behavioural and physiological symptoms related to dementia, proposing personalised interventions aimed at supporting patients and their relatives from diagnosis until death. With particular reference to long-term settings, in this work, we aim at understanding the organisational implications of three types of interventions (labelled supportive care interventions – SCIs) that have characterised this shift in dementia care: person-centred, palliative and multi-disciplinary care. Conducted by following the integrative review method, our review underlines how SCIs have controversial consequences on the quality of care, the care-givers’ quality of life and cultural backgrounds. After an in-depth analysis of selected papers, we offer some considerations about the implications of SCIs for long-term care organisations and future research directions.