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BACKGROUND

An informant-based screening tool for dementia may be useful in population-based studies of minority populations.

OBJECTIVE

Investigate the feasibility of screening for very mild dementia in a community sample of African Americans using an informant-based screening tool (AD8).

DESIGN

Cohort study

PARTICIPANTS

147 persons from the African American Health (AAH) project were screened for dementia; 61 of 93 who were invited had follow-up clinical assessments for dementia diagnosis.

MEASUREMENTS

The AD8, Mini-Mental State Examination (MMSE), Short Blessed Test (SBT), Brief Instrument for Dementia Detection (BIDD), and a neuropsychological battery were administered at visit 1. The Clinical Dementia Rating (CDR) was administered at visit 2 by clinicians blinded to visit 1 results; the presence of dementia was determined by a CDR greater than 0.

RESULTS

465 individuals from the AAH cohort were sent a letter describing the study and, among this group, 252 individuals were contacted by phone to request participation in this study. 6% (14 / 252) of participants contacted by phone were unable to identify an informant (required for the AD8). 150 individuals agreed by phone to participate of which 2% (n=3) did not have an informant available at the time of participation. The AD8 alone was effective at discriminating between CDR 0 and CDR 0.5 (area under the curve = .847; p <.001; 95% confidence interval 0.73-0.96).

CONCLUSIONS

A brief informant-based instrument, the AD8, has high sensitivity and specificity for distinguishing CDR 0 from CDR 0.5 in the community. Informant availability may not be a barrier to using the AD8 in an African American community sample; however, further study in larger samples with a higher response rate, different community settings (e.g., community clinics), and among older age groups (e.g., age 75+) is warranted to confirm this.

Neuropsychological tests are instruments used to diagnose a variety of cognitive conditions. This article will review a few of the brief scales commonly used in screening for dementia. It will also discuss the properties of and problems with some of the brief scales that are commonly used to screen African Americans for dementia, highlighting the various biases. The Mini-Mental State Examination (MMSE) is the most widely known and utilized cognitive impairment instrument in the United States. Whether or not it is biased to race after adjusting the scores for educational attainment remains controversial. The Blessed Information-Memory-Concentration Test (BIMC), Blessed Orientation-Memory-Concentration Test (BOMC), Short Portable Mental Status Questionnaire (SPMSQ), and Neurobehavioral Cognitive Status Examination (NCSE) are other screening tests used to diagnose dementia. Some of these tests have been found to misclassify many more African Americans as demented compared to the proportion of whites that are misclassified. The Cambridge Cognitive Examination (CAMCOG) is the only brief neuropsychological scale designed to actually diagnose early dementia, but it is not known if it is biased for African Americans.

Background:

Due to the high prevalence of mild cognitive impairment (MCI) and dementia in Parkinson disease (PD), routine cognitive screening is important for the optimal management of patients with PD. The Montreal Cognitive Assessment (MoCA) is more sensitive than the commonly used Mini-Mental State Examination (MMSE) in detecting MCI and dementia in patients without PD, but its validity in PD has not been established.

Methods:

A representative sample of 132 patients with PD at 2 movement disorders centers was administered the MoCA, MMSE, and a neuropsychological battery with operationalized criteria for deficits. MCI and PD dementia (PDD) criteria were applied by an investigator blinded to the MoCA and MMSE results. The discriminant validity of the MoCA and MMSE as screening and diagnostic instruments was ascertained.

Results:

Approximately one third of the sample met diagnostic criteria for a cognitive disorder (12.9% PDD and 17.4% MCI). Mean (SD) MoCA and MMSE scores were 25.0 (3.8) and 28.1 (2.0). The overall discriminant validity for detection of any cognitive disorder was similar for the MoCA and the MMSE (receiver operating characteristic area under the curve [95% confidence interval]): MoCA (0.79 [0.72, 0.87]) and MMSE (0.76 [0.67, 0.85]), but as a screening instrument the MoCA (optimal cutoff point = 26/27, 64% correctly diagnosed, lack of ceiling effect) was superior to the MMSE (optimal cutoff point = 29/30, 54% correctly diagnosed, presence of ceiling effect).

Conclusions:

The Montreal Cognitive Assessment, but not the Mini-Mental State Examination, has adequate psychometric properties as a screening instrument for the detection of mild cognitive impairment or dementia in Parkinson disease. However, a positive screen using either instrument requires additional assessment due to suboptimal specificity at the recommended screening cutoff point.

GLOSSARY

= Alzheimer disease;

= area under the curve;

= deep brain stimulation;

= Diagnostic and Statistical Manual of Mental Disorders, 4th edition;

= Geriatric Depression Scale;

= Hopkins Verbal Learning Test;

= instrumental activities of daily living;

= mild cognitive impairment;

= Mini-Mental State Examination;

= Montreal Cognitive Assessment;

= negative predictive value;

= Parkinson disease;

= Parkinson disease dementia;

= positive predictive value;

= quality of life;

= receiver operating characteristic;

= Tower of London-Drexel;

= Unified Parkinson’s Disease Rating Scale.

Introduction

The objective of this study was to evaluate emergency medicine physician and nurse acceptance of nonnurse, nonphysician screening for geriatric syndromes.

Methods

This was a single-center emergency department (ED) survey of physicians and nurses after an 8-month project. Geriatric technicians were paid medical student research assistants evaluating consenting ED patients older than 65 years for cognitive dysfunction, fall risk, or functional decline. The primary objective of this anonymous survey was to evaluate ED nurse and physician perceptions about the geriatric screener feasibility and barriers to implementation. In addition, as a secondary objective, respondents reported ongoing geriatric screening efforts independent of the research screeners.

Results

The survey was completed by 72% of physicians and 33% of nurses. Most nurses and physicians identified geriatric technicians as beneficial to patients without impeding ED throughput. Fewer than 25% of physicians routinely screen for any geriatric syndromes. Nurses evaluated for fall risk significantly more often than physicians, but no other significant differences were noted in ongoing screening efforts.

Conclusion

Dedicated geriatric technicians are perceived by nurses and physicians as beneficial to patients with the potential to improve patient safety and clinical outcomes. Most nurses and physicians are not currently screening for any geriatric syndromes.

The STarT back screening tool (SBT) allocates low back pain (LBP) patients into three risk groups and is intended to assist clinicians in their decisions about choice of treatment. The tool consists of domains from larger questionnaires that previously have been shown to be predictive of non-recovery from LBP. This study was performed to describe the distribution of depression, fear avoidance and catastrophising in relation to the SBT risk groups. A total of 475 primary care patients were included from 19 chiropractic clinics. They completed the SBT, the Major Depression Inventory (MDI), the Fear Avoidance Beliefs Questionnaire (FABQ), and the Coping Strategies Questionnaire. Associations between the continuous scores of the psychological questionnaires and the SBT were tested by means of linear regression, and the diagnostic performance of the SBT in relation to the other questionnaires was described in terms of sensitivity, specificity and likelihood ratios.

In this cohort 59% were in the SBT low risk, 29% in the medium risk and 11% in high risk group. The SBT risk groups were positively associated with all of the psychological questionnaires. The SBT high risk group had positive likelihood ratios for having a risk profile on the psychological scales ranging from 3.8 (95% CI 2.3 - 6.3) for the MDI to 7.6 (95% CI 4.9 - 11.7) for the FABQ. The SBT questionnaire was feasible to use in chiropractic practice and risk groups were related to the presence of well-established psychological prognostic factors. If the tool proves to predict prognosis in future studies, it would be a relevant alternative in clinical practice to other more comprehensive questionnaires.

Introduction

Clinicians require brief, practical tools to help identify low back pain (LBP) subgroups requiring early, targeted secondary prevention. The STarT Back Tool (SBT) was recently validated to subgroup LBP patients into early treatment pathways.

Aim

To test the SBT’s concurrent validity against an existing, popular LBP subgrouping tool, the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ), and to compare the clinical characteristics of subgroups identified by each tool.

Methods

Two hundred and forty-four consecutive ‘non-specific’ LBP consulters at 8 UK GP practices aged 18–59 years were invited to complete a questionnaire. Measures included the ÖMPSQ and SBT, disability, fear, catastrophising, pain intensity, episode duration and demographics. Instruments were compared using Spearman’s correlations, tests for subgroup agreement and discriminant analysis of subgroup characteristics according to reference standards.

Results

Completed SBT (9-items) and ÖMPSQ (24-items) data was available for 130/244 patients (53%). The correlation of SBT and ÖMPSQ scores was ‘excellent (rs = 0.80). Subgroup characteristics were similar across the low, medium and high subgroups, but, the proportions allocated to ‘low’, ‘medium’ and ‘high’ risk groups were different, with fewer patients in the SBT’s high risk group. Both instruments similarly discriminated for reference standards such as disability, catastrophising, fear, comorbid pain and time off work. The ÖMPSQ was better at discriminating pain intensity, while the SBT was better for discriminating bothersomeness of back pain and referred leg pain.

Conclusions

The SBT baseline psychometrics performed similarly to the ÖMPSQ, but the SBT is shorter and easier to score and is an appropriate alternative for identifying high risk LBP patients in primary care.

Objective

Self-administered by spouses and other collateral informants, the nationally normed Older Adult Behavior Checklist (OABCL) provides standardized data on diverse aspects of older adult psychopathology and adaptive functioning. We tested the validity of the Older Adult Behavior Checklist (OABCL) scale scores in terms of associations with diagnoses of dementia of the Alzheimer’s type (DAT) and mood disorders (MD) and with 9 measures of psychopathology, cognitive performance, and adaptive functioning.

Method

Informants completed OABCLs for 727 60- to 97-year-olds recruited from a memory disorders clinic, geriatric psychiatry clinic, and community–dwelling seniors. OABCL scale scores were tested for associations with DAT and MD diagnoses, as well as with scores on the Neuropsychiatric Inventory, Mini-Mental State Exam (MMSE), Clock Drawing Test, Alzheimer’s Disease Assessment Scale, Geriatric Depression Scale, Clinical Dementia Rating, Dementia Severity Rating Scale, Trail Making Test Part A, and Instrumental Activities of Daily Living.

Results

OABCL scales had medium to large correlations with the 9 other indices of functioning and significantly augmented MMSE discrimination between patients with DAT vs. MD. OABCL scales also discriminated significantly between patients diagnosed with DAT vs. MD and both these groups vs. nonclinical subjects.

Conclusions

Multiple OABCL scales had medium to large associations with diverse indices of functioning based on other kinds of data. The nationally normed OABCL provides new ways to integrate informant and self-report data to improve assessment of older adults. Specifically, the OABCL can provide discrimination between those who qualify for diagnoses of DAT vs. MD vs. neither diagnosis.

Background

Telephone interviews are widely used in geriatric settings to identify eligible research participants and to perform brief follow-up assessments of cognition. This article reports on the development and validation of the Memory and Aging Telephone Screen (MATS), a structured interview for older adults with mild cognitive impairment and/or significant memory complaints. We also developed three alternate forms of the MATS objective memory test to reduce practice effects engendered by multiple administrations.

Methods

Participants were enrolled in a longitudinal study that included 120 older adults with amnestic mild cognitive impairment (MCI), subjective cognitive complaints (CC) but without deficit on neuropsychological tests, and demographically-matched healthy controls (HC). An additional 15 patients with mild probable Alzheimer's disease (AD) completed the alternative forms study. All participants received the original MATS version, and a subset (n = 90) later received two of three alternate forms.

Results

The MATS was sensitive to group differences and the alternate forms were equivalent. MATS objective memory test scores showed adequate stability over one year and were moderately correlated with scores on a widely used list-learning test (CVLT-II).

Conclusions

The MATS, a repeatable telephone screen that includes objective and subjective memory assessments, is useful for detecting individuals in the preclinical and early stages of dementia. Results encourage use of the MATS as a reliable and valid cognitive screening tool in research and clinical settings. Longitudinal assessments are being performed to investigate the predictive validity of the MATS for cognitive progression in MCI.

Screening tests for Alzheimer’s disease lack sensitivity and specificity. We developed the AD8, a brief dementia screening interview validated against clinical and cognitive evaluations, as an improvement over current screening methods. Because insufficient follow-up has occurred to validate the AD8 against the neuropathologic findings of Alzheimer’s disease, we investigated whether AD8 scores correspond to impairment in episodic memory testing and changes in biomarkers of Alzheimer’s disease (cerebrospinal fluid and amyloid imaging with Pittsburgh compound B) characteristic of symptomatic Alzheimer’s disease. We also compared informant-based assessments with brief performance-based dementia screening measurements such as the Mini Mental State Exam. The sample (n = 257) had a mean age of 75.4 years with 15.1 years of education; 88.7% were Caucasian and 45.5% were male. The sample was divided into two groups based on their AD8 scores: those with a negative dementia screening test (AD8 score 0 or 1, n = 137) and those with a positive dementia screening test (AD8 score ≥2, n = 120). Individuals with positive AD8 scores had abnormal Pittsburgh compound B binding (P < 0.001) and cerebrospinal fluid biomarkers (P < 0.001) compared with individuals with negative AD8 scores. Individuals with positive AD8 tests and positive biomarkers scored in the impaired range on the Wechsler Logical Memory Story A (mean score 7.0 ± 4.5 for Pittsburgh compound B; mean score 7.6 ± 5.3 for cerebrospinal fluid amyloid beta protein 1–42). The AD8 area under the curve for Pittsburgh compound B was 0.737 (95% confidence interval: 0.64–0.83) and for cerebrospinal fluid amyloid beta protein 1–42 was 0.685 (95% confidence interval: 0.60–0.77) suggesting good discrimination. The AD8 had superior sensitivity in detecting early stages of dementia compared with the Mini Mental State Examination. The AD8 had a likelihood ratio of a positive test of 5.8 (95% confidence interval: 5.4–6.3) and likelihood ratio of a negative test of 0.04 (95% confidence interval: 0.03–0.06), increasing the pre-test probability of an individual having symptomatic Alzheimer’s disease. Individuals with AD8 scores of ≥2 had a biomarker phenotype consistent with Alzheimer’s disease and lower performance on episodic memory tests, supporting a diagnosis of Alzheimer’s disease. Informant-based assessments may be superior to performance-based screening measures such as the Mini Mental State Examination in corresponding to underlying Alzheimer’s disease pathology, particularly at the earliest stages of decline. The use of a brief test such as the AD8 may improve strategies for detecting dementia in community settings where biomarkers may not be readily available, and may enrich clinical trial recruitment by increasing the likelihood that participants have underlying biomarker abnormalities.

Background

Despite worldwide recognition of the burden of dementia, no epidemiological data is yet available in Portugal. The objective of this study is to estimate the prevalence and describe the pattern of cognitive impairment with dementia or no dementia (CIND) in rural and urban populations from Northern Portugal.

Methods

Two random samples of residents aged 55 to 79 years in rural and urban communities were drawn from the health centres registries to be screened for cognitive impairment. The screening criteria for dementia were an abnormal Mini-Mental State Examination (MMSE) score or a Blessed Dementia Scale score. After excluding those who tested positive for dementia, cut-off points for CIND were set at 1 standard deviation below the mean of the MMSE according to educational level. All those who screened positive either for dementia or CIND were examined by a neurologist for establishing a definitive diagnosis.

Results

The prevalence of cognitive impairment was higher in rural than in urban populations, 16.8% (95% CI: 14.3-19.8%) vs. 12.0% (95%CI: 9.3-15.4%), with a rural/urban prevalence ratio (PR) of 2.16 (95% CI: 1.04-4.50) in the eldest and 2.19 (95% CI: 1.01-4.76) in persons with vascular risk factors. The prevalence of dementia was 2.7% (95% CI: 1.9-3.8%) with a rural/urban PR = 2.1 and the prevalence of CIND was 12.3% (95% CI: 10.4-14.4%) and PR = 1.3. The prevalence of dementia increases exponentially with age and in those with cerebrovascular disease or other comorbid conditions while the prevalence of CIND, besides these factors, is also higher in persons with low levels of education or vascular risk factors. Alzheimer's and vascular disease were equally likely aetiologies of dementia (38.7%), the later more common in men PR(F:M = 0.3) as opposed to the former PR(F:M = 2.0). Vascular CIND, associated either with cerebrovascular disease or vascular risk factors was more frequent (39.7%) then depression (18.4%) or any other aetiology.

Conclusions

The prevalence of cognitive impairment is higher in rural compared with urban populations. This is shown in the synergy between age and rurality, with the rural/urban prevalence ratio increasing with age. In this relatively young population from Northern Portugal, cerebrovascular disease as well as vascular risk factors account for 48% of overall cognitive impairment.

Background: cerebral small vessel disease (SVD) is the most common cause of vascular cognitive impairment (VCI). Despite this, there is a paucity of rapid simple screening tools to identify cognitive impairment in SVD and differentiate it from other common dementia types.

Objective: to validate a new screening test for cognitive impairment in SVD, the Brief Memory and Executive Test (BMET) battery, and examine its ability to detect SVD and differentiate it from Alzheimer's disease (AD).

Subjects: 45 patients with SVD, 27 patients with AD and 80 normal controls.

Methods: the BMET includes brief tests of executive functioning and processing speed, with comparative tests of memory and orientation. Group discrimination was calculated using discriminant function analysis.

Results: the BMET took an average of 10 min to administer. It showed high sensitivity (91%) and specificity (85%) in differentiating SVD patients with cognitive impairment from AD patients. As a comparison the mini-mental state examination had lower sensitivity (63%) and specificity (62%).

Conclusions: the BMET is a simple and quick to administer clinical tool for the detection of VCI in SVD and its differentiation from AD impairment. Further multicentre studies are required to evaluate and compare it with other existing screening tests.

Background:

With the large number of aging individuals requiring screening of cognitive functions for dementing illnesses, there is a necessity for innovative evaluation approaches. One domain that should allow for online, at a distance, examination is speech and language dysfunction, if the auditory and visual transmission is of sufficient quality to allow adequate patient participation and reliable, valid interpretation of signs and symptoms (Duffy et al 1997).

Objective:

Examine the effectiveness of language assessment in mild Alzheimer’s patients using telemedicine (TM) compared with traditional in-person (IP) assessment.

Design:

Ten patients with mild Alzheimer’s disease, enrolled at a Geriatric Memory Clinic received a battery of standard language tests under two conditions: face-to-face and via satellite TM.

Results:

Comparison of TM and IP testing conditions were assessed within each for scores on each test in the two conditions. On each of the five language tasks, the Wilcoxon signed ranks test indicated no significant difference on performance between the TM and IP conditions for each participant. Overall acceptance of the TM evaluation in an elderly population was rated at a high level except for one individual.

Conclusion:

Telemedicine can improve access to speech and language evaluation services which is relevant to both dementia and other neurological diseases of the elderly. In particular, this specific assessment tool can be used to provide evaluations in under-served rural areas.

Study objective

We evaluate the diagnostic test characteristics of the Six-Item Screener and the AD8 to detect cognitive dysfunction in adults older than 65 years and using the emergency department (ED) for any reason.

Methods

We conducted an observational cross-sectional cohort study at a single academic urban university-affiliated hospital. Subjects were consenting, non-critically ill, English-speaking adults older than 65 years and receiving care in the ED. We quantitatively assessed the diagnostic test characteristics of the Six-Item Screener and AD8 by using the Mini-Mental State Examination score less than 24 as the criterion standard for cognitive dysfunction.

Results

The prevalence of cognitive dysfunction was 35%, but only 6% of charts noted a pre-existing deficit. The Six-Item Screener was superior to either the caregiver-administered AD8 or the patient-administered AD8 for the detection of cognitive dysfunction.

Conclusion

The Six-Item Screener was superior to the caregiver- or patient-administered AD8 to identify older adults at increased risk for occult cognitive dysfunction.

Aim

It is highly desirable to develop a neuropsychological screening test which is sensitive to the early stage of Alzheimer’s disease (AD), and is easy to administer at the primary care physician’s (PCP’s) office.

Methods

Participants were 128 AD patients and 54 healthy volunteers. Brief cognitive screening tests were administered to the participants including the Mini-Mental State Examination (MMSE), Clock Drawing Test (CDT), Verbal Fluency Test (VFT), a Verbal Category Cued Memory test (CCMT) and the Scenery Picture Memory Test (SPMT). In the SPMT, a scenery picture of a living room containing 23 familiar objects was used. The administration of the SPMT comprised the first shallow memory session (Pict 1) and the second deep memory session (Pict 2). The area under the receiver–operator curve (AUC) was used to compare the efficacy of SPMT with other cognitive tests.

Results

Pict 1, which requires less than 2 min to complete, had the same AUC as Pict 2, and showed significantly larger AUC than MMSE, CDT and VFT for all (MMSE 19–23) and very mild (MMSE ≥ 24) AD patients. When we conducted the similar analysis separately for those younger than 75 years and those aged 75 years or older, we obtained the same results as above among the older age group. Pict 1 showed larger AUC than CCMT in overall sample and also in the older age group, although the difference was not statistically significant.

Conclusion

The SPMT could be useful for detection of mild and very mild AD in settings even where time is limited.

Objectives: To examine the ability of a brief and simple cognitive screening test to detect cognitive deficits in atypical parkinsonian syndromes.

Methods: Addenbrooke's cognitive examination (ACE), the mini-mental state examination (MMSE), and the dementia rating scale (DRS) were applied to 26 patients with multiple system atrophy (MSA), 39 with progressive supranuclear palsy (PSP), and 25 with corticobasal degeneration (CBD). The results were then compared with those obtained in 30 healthy age matched volunteers and 30 patients with Alzheimer's disease.

Results: In all four diseases the rate of detection of cognitive impairment on ACE was higher than on MMSE and comparable with DRS. The severity of cognitive impairment was most pronounced in the CBD group, which showed a similar degree of impairment to the Alzheimer group. In contrast, MSA patients were the least cognitively impaired. The PSP group took an intermediate position.

Conclusions: Cognitive impairment in atypical parkinsonian syndromes can be detected using a brief and clinically applicable bedside test such as ACE.

Background: Cerebral small vessel disease is a common cause of cognitive impairment and vascular dementia. The cognitive deficit differs from that in Alzheimer's disease, with greater executive/attentional dysfunction and relatively intact episodic memory.

Objective: To develop brief assessment tools that are better adapted to the neuropsychological profile of cerebral small vessel disease.

Methods: 32 subjects with ischaemic leukoaraiosis (history of lacunar stroke and leukoaraiosis on MRI), aged 50 to 84 years, and 17 age and education matched controls had a brief executive assessment, which took 20 minutes to administer, and a wide range of additional tests. The ability of the brief executive assessment to discriminate between groups—both individually and in combination—was evaluated and compared with that of the whole battery.

Results: The brief executive assessment provided good sensitivity and specificity for identifying subjects with ischaemic leukoaraiosis (sensitivity 88%, specificity 88%, using the optimal combination of scores). The best individual tests were trail making and digit symbol, which were both far more sensitive than the mini-mental state examination (MMSE). The ability to discriminate between groups was maintained in subjects with MMSE >27 and across the whole age range. The brief executive assessment performed well compared with the whole battery, with additional tests accounting for only a further 12% of between-group variance.

Conclusions: The brief executive assessment was sensitive to deficits found in ischaemic leukoaraiosis and discriminated them from the cognitive effects of healthy aging. The assessment has potential for bedside use and as a cognitive end point for clinical trials.

The present study was carried out on the hospitalised geriatric general medical patients. The assessment of the patients was carried out within 24 hours of admission and on every fourth day thereafter using Mini Mental Status Examination (MMSE), Confusion Assessment Method (CAM), Delirium Symptom Interview (DSI) and ICD-10-Diagnostic Criteria of Research for delirium. An overall rate of delirium of 27% was found in the 100 patients who constituted the sample. 19% was the rate of ‘prevalent’ delirium and 8% was the rate of ‘incident’ delirium. It is observed that the CAM is a useful screening method with high sensitivity for diagnosis of delirium at the bedside.

OBJECTIVE

To evaluate the association between cognitive dysfunction and other barriers and glycemic control in older adults with diabetes.

RESEARCH DESIGN AND METHODS

Patients over the age of 70 years presenting to a geriatric diabetes clinic were evaluated for barriers to successful diabetes management. Patients were screened for cognitive dysfunction with the Mini Mental State Examination (MMSE) and a clock-drawing test (CDT) scored by 1) a method validated by Mendez et al. and 2) a modified CDT (clock in a box [CIB]). Depression was evaluated with the Geriatric Depression Scale. Interview questionnaires surveyed activities of daily living (ADLs) and instrumental ADLs (IADLs), as well as other functional disabilities.

RESULTS

Sixty patients (age 79 ± 5 years, diabetes duration 14 ± 13 years) were evaluated. Thirty-four percent of patients had low CIB (≤5), and 38% of patients had low CDT (≤13). Both CIB as well as CDT were inversely correlated with HbA1c, suggesting that cognitive dysfunction is associated with poor glycemic control (r = −0.37, P < 0.004 and r = −0.38, P < 0.004, respectively). Thirty-three percent of patients had depressive symptoms with greater difficulty completing the tasks of the IADL survey (5.7 ± 1.7 vs. 4.6 ± 2.0; P < 0.03). These older adults with diabetes had a high incidence of functional disabilities, including hearing impairment (48%), vision impairment (53%), history of recent falls (33%), fear of falls (44%), and difficulty performing IADLs (39%).

CONCLUSIONS

Older adults with diabetes have a high risk of undiagnosed cognitive dysfunction, depression, and functional disabilities. Cognitive dysfunction in this population is associated with poor diabetes control.

Objective:

To examine the impact of delirium on the trajectory of cognitive function in a cohort of patients with Alzheimer disease (AD).

Methods:

A secondary analysis of data collected from a large prospective cohort, the Massachusetts Alzheimer’s Disease Research Center’s patient registry, examined cognitive performance over time in patients who developed (n = 72) or did not develop (n = 336) delirium during the course of their illnesses. Cognitive performance was measured by change in score on the Information-Memory-Concentration (IMC) subtest of the Blessed Dementia Rating Scale. Delirium was identified using a previously validated chart review method. Using linear mixed regression models, rates of cognitive change were calculated, controlling for age, sex, education, comorbid medical diagnoses, family history of dementia, dementia severity score, and duration of symptoms before diagnosis.

Results:

A significant acceleration in the slope of cognitive decline occurs following an episode of delirium. Among patients who developed delirium, the average decline at baseline for performance on the IMC was 2.5 points per year, but after an episode of delirium there was further decline to an average of 4.9 points per year (p = 0.001). Across groups, the rate of change in IMC score occurred about three times faster in those who had delirium compared to those who did not.

Conclusions:

Delirium can accelerate the trajectory of cognitive decline in patients with Alzheimer disease (AD). The information from this study provides the foundation for future randomized intervention studies to determine whether prevention of delirium might ameliorate or delay cognitive decline in patients with AD.

GLOSSARY

= Alzheimer disease;

= Clinical Dementia Rating;

= Information-Memory-Concentration subtest of the Blessed Dementia Rating Scale;

= Massachusetts Alzheimer’s Disease Research Center;

= Massachusetts General Hospital.

Objective: To describe the effect of cholinesterase inhibitors (CEIs) on the natural course of Alzheimer's disease (AD).

Methods: The short and long term effects of CEIs were evaluated in 135 patients with probable Alzheimer's disease relative to 135 patients who were never exposed to CEIs matched by age, education, duration of the symptoms, and cognitive status. We measured 1 year change in cognitive and functional performance, and the likelihood of arriving at each of four end points: (1) mini mental state examination (MMSE) of 9 or lower, (2) Blessed dementia rating scale for activities of daily living of 12 or higher, (3) nursing home admission, and (4) death, over an average 3 years of observation (36.7 (SD 21.5) months).

Results: Patients on CEIs were better cognitively and functionally after 1 year compared with those patients who never used CEIs. A proportional hazard analysis with CEI use as a time dependent covariate showed that the use of CEIs decreased the risk of nursing home admission. There was no association, however, between use of CEIs and time to cognitive and functional end points, or to death.

Conclusions: This observational study showed that there was an initial cognitive and functional benefit from the use of CEIs in Alzheimer's disease, which waned as the disease progressed. However, the results suggest that there is a long term beneficial effect of the use of CEIs, as indicated by the delay in adsmission to nursing homes.

Objective

The primary purpose of this study was to investigate the differences in the serum brain-derived neurotrophic factor (BDNF) level between elderly Korean people over 65 years with and without dementia.

Methods

171 individuals over 65 years were enrolled in this study. Screening for cognitive impairments was carried out using the Mini-Mental Status Examination-Korean version (MMSE-KC). One hundred thirty-two subjects scored below 1.5 standard deviations (SD) of the mean MMSE-KC score, and these were evaluated using the Consortium to Establish a Registry for Alzheimer's Disease, Korean version (CERAD-K) and the Geriatric Depression Scale (GDS). The Clinical Dementia Rating Scale (CDRS) and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) diagnostic criteria were used for further evaluation. Subjects with a CDRS score of 1 or higher were classified as having Alzheimer's disease (AD), and subjects with a CDRS score of 0.5 were classified as having a mild cognitive impairment (MCI). Subjects with a CDRS score of 0 were classified as having aging-associated cognitive decline (AACD). Serum BDNF levels were analyzed using the enzyme-linked immunosorbent assay (ELISA) method.

Results

The serum BDNF levels were significantly lower in the subjects with MCI and AD compared with the healthy controls (p<0.01). A significant correlation was found between the total MMSE-KC score and serum BDNF level (r=0.295; p<0.01). However, no significant correlation was observed between the severity of MMSE-KC and the total GDS score. A significant difference was found in the total score of GDS between the AACD group and subjects with AD (p<0.05).

Conclusion

This study suggested that BDNF might be involved in the pathophysiology of cognitive decline in elderly people.

Objective To evaluate a cognitive test, the TYM (“test your memory”), in the detection of Alzheimer’s disease.

Design Cross sectional study.

Setting Outpatient departments in three hospitals, including a memory clinic.

Participants 540 control participants aged 18-95 and 139 patients attending a memory clinic with dementia/amnestic mild cognitive impairment.

Intervention Cognitive test designed to use minimal operator time and to be suitable for non-specialist use.

Main outcome measures Performance of normal controls on the TYM. Performance of patients with Alzheimer’s disease on the TYM compared with age matched controls. Validation of the TYM with two standard tests (the mini-mental state examination (MMSE) and the Addenbrooke’s cognitive examination-revised (ACE-R)). Sensitivity and specificity of the TYM in the detection of Alzheimer’s disease.

Results Control participants completed the TYM with an average score of 47/50. Patients with Alzheimer’s disease scored an average of 33/50. The TYM score shows excellent correlation with the two standard tests. A score of ≤42/50 had a sensitivity of 93% and specificity of 86% in the diagnosis of Alzheimer’s disease. The TYM was more sensitive in detection of Alzheimer’s disease than the mini-mental examination, detecting 93% of patients compared with 52% for the mini-mental state exxamination. The negative and positive predictive values of the TYM with the cut off of ≤42 were 99% and 42% with a prevalence of Alzheimer’s disease of 10%. Thirty one patients with non-Alzheimer dementias scored an average of 39/50.

Conclusions The TYM can be completed quickly and accurately by normal controls. It is a powerful and valid screening test for the detection of Alzheimer’s disease.

Abstract

Objective. To validate A Quick Test of Cognitive Speed (AQT) as an instrument in diagnostic dementia evaluations against final clinical diagnosis and compare AQT with the Mini-Mental State Examination (MMSE) and Clock Drawing Test (CDT) in primary care. Design. Primary health care cohort survey. Setting. Four primary health care centres and a geriatric memory clinic in Sweden. Patients. 81 patients (age 65 and above) were included: 52 with cognitive symptoms and 29 presumed cognitively healthy. None of the patients had a previous documented dementia diagnosis. All patients performed MMSE, CDT, and AQT at the primary health care clinic and were referred for extensive neuropsychological testing at a memory clinic. AQT was validated against final clinical diagnosis determined by a geriatric specialist and a neuropsychologist. Main outcome measures. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratios, correlation data, and receiver operating characteristic (ROC). Results. For MMSE, sensitivity and specificity was 0.587 and 0.909; CDT 0.261 and 0.879; and AQT 0.783 and 0.667, respectively. For the combination of MMSE and CDT, sensitivity and specificity was 0.696 and 0.788, for MMSE and AQT 0.913 and 0.636. The ROC curve for AQT showed an area under curve (AUC) of 0.773. Conclusion. Our results suggest AQT is a usable test for dementia assessments in primary care. Sensitivity for AQT is superior to CDT, equivalent to MMSE, and comparable to the combination MMSE and CDT. MMSE in combination with AQT improves sensitivity. Because AQT is user-friendly and quickly administered, it could be applicable for primary care settings.

Objectives

To assess whether the core symptoms of Alzheimer’s disease (AD) and caregiver factors consistently predict family caregiver ratings of patient quality of life (QOL) as assessed by a variety of QOL measures in a large national sample.

Design

Cross-sectional.

Setting

Fifteen dementia and geriatric clinics across Canada.

Participants

Family caregivers (n = 412) of community-living patients with AD of all severities.

Measurements

Caregiver ratings of patient QOL using three utility indexes, the EQ-5D, Quality of Well-Being Scale and Health Utilities Index, a global QOL visual analogue scale, a disease-specific measure, the QOL-AD, and a generic health status measure, the Short Form-36. Patient cognition was assessed with the AD Assessment Scale-Cognitive Subscale and Mini-Mental State Examination, function with the Disability Assessment for Dementia, and behavioral and psychological symptoms with the Neuropsychiatric Inventory and the Geriatric Depression Scale. Caregiver burden was assessed with the Zarit Burden Interview and caregiver depression with the Center for Epidemiologic Studies-Depression scale. One-way analysis of variance and fully adjusted multiple linear regression were used to assess the relationship between patient dementia symptom and caregiver variables with QOL ratings.

Results

In multivariable analyses, caregiver ratings of patient function and depressive symptoms were the only consistent independent predictors of caregiver-rated QOL across the QOL measures.

Conclusions

Caregiver ratings of patient function and depression were consistent independent predictors of caregiver-rated QOL using a spectrum of QOL measures, while measures of patient cognition and caregiver burden and depression were not. These findings support the continued use of caregiver ratings as an important source of information about patient QOL and endorse the inclusion in AD clinical trials of caregiver-rated measures of patient function, depression and QOL.

Background

Delirium in older hospital inpatients appears to be associated with various adverse outcomes. The limitations of previous research on this association have included small sample sizes, short follow-up periods and lack of consideration of important confounders or modifiers, such as severity of illness, comorbidity and dementia. The objective of this study was to determine the prognostic significance of delirium, with or without dementia, for cognitive and functional status during the 12 months after hospital admission, independent of premorbid function, comorbidity, severity of illness and other potentially confounding variables.

Methods

Patients 65 years of age and older who were admitted from the emergency department to the medical services were screened for delirium during their first week in hospital. Two cohorts were enrolled: patients with prevalent or incident delirium and patients without delirium, but similar in age and cognitive impairment. The patients were followed up at 2, 6 and 12 months after hospital admission. Analyses were conducted for 4 patient groups: 56 with delirium, 53 with dementia, 164 with both conditions and 42 with neither. Baseline measures included delirium (Confusion Assessment Method), dementia (Informant Questionnaire on Cognitive Decline in the Elderly), physical function (Barthel Index [BI] and premorbid instrumental activities of daily living, IADL), the Mini-Mental State Examination (MMSE), comorbidity, and physiologic and clinical severity of illness. Outcome variables measured at follow-up were the MMSE, Barthel Index, IADL and admission to a long-term care facility.

Results

After adjustment for covariates, the mean differences in MMSE scores at follow-up between patients with and without delirium were –4.99 (95% confidence interval [CI] –7.17 to –2.81) for patients with dementia and –3.36 (95% CI –6.15 to –0.58) for those without dementia. At 12 months, the adjusted mean differences in the BI were –16.45 (95% CI –27.42 to –5.50) and –13.89 (95% CI –28.39 to 0.61) for patients with and without dementia respectively. Patients with both delirium and dementia were more likely to be admitted to long-term care than those with neither condition (adjusted odds ratio 3.18, 95% CI 1.19 to 8.49). Dementia but not delirium predicted worse IADL scores at follow-up. Unadjusted analyses yielded similar results.

Interpretation

For older patients with and without dementia, delirium is an independent predictor of sustained poor cognitive and functional status during the year after a medical admission to hospital.