"iDoctor – Medical Blog"

Behavioral and Psychological Symptoms of Dementia (BPSD) are increasingly recognized as a major risk factor for caregiver burden, institutionalization, greater impairment in activities of daily living (ADLs), more rapid cognitive decline, and a poorer quality of life. BPSD contribute significantly to the direct and indirect costs of caring for patients with dementia even after adjusting for the severity of cognitive impairment and other co-morbidities. Research on these symptoms has indicated a complex interplay between the biological, psychological and social factors involved in the disease process. Although some psychotropic medications have shown modest efficacy in the treatment of these behaviors, their use has generated controversy due to increasing recognition of the side effects of these medications especially the antipsychotic medications. In this review, we examine the risk of cerebrovascular adverse events (CVAEs) and death with antipsychotic medications when used to treat elderly patients with dementia.

Early-onset Alzheimer’s disease (EOAD), defined as affecting those under age 65, afflicts between 200,000 and 500,000 people in the US. EOAD tends to be a fast-progressing and aggressive form of AD. There is a beginning body of research exploring EOAD patients’ experience and needs, as well as that of their primary family caregivers, often spouses. However, there has been very little written about the experience and needs of EOAD patients’ children, who because of the early onset, and increasing postponement of childbearing, may be latency-aged or in their early teens. This paper reviews existing and related literature in this area, and illustrates the psychosocial impact on children using the case of a 50 year-old father diagnosed with AD and his 16 year-old daughter and 11 year-old son. The need for increased research and program development to address these children’s needs is discussed.

Purpose: The aim of this study was to examine the impact on dementia caregivers’ experienced stress and health status of 2 Internet-based intervention programs. Design and methods: Ninety-one dementia caregivers were given the choice of being involved in either an Internet-based chat support group or an Internet-based video conferencing support group. Pre-post outcome measures focused on distress, health status, social support, and service utilization. Results: In contrast to the Chat Group, the Video Group showed significantly greater improvement in mental health status. Also, for the Video Group, improvements in self-efficacy, neuroticism, and social support were associated with lower stress response to coping with the care recipient’s cognitive impairment and decline in function. Implications: The results show that, of 2 Internet-based intervention programs for dementia caregivers, the video conferencing intervention program was more effective in improving mental health status and improvement in personal characteristics were associated with lower caregiver stress response.

Aims: To estimate the use of different types of physical restraints and assess their associations to falls and injuries among residents with and without Alzheimer’s disease (AD) or dementia in US nursing homes. Methods: Data were from the 2004 National Nursing Home Survey. AD or dementia was identified using International Classification of Diseases, Ninth Revision (ICD-9) codes. Analyses were conducted with the Surveyfreq and Surveylogistic procedures in SAS v.9.1. Results: Residents with either AD or dementia were more likely to be physically restrained (9.99% vs 3.91%, P < .001) and less likely to have bed rails (35.06% vs 38.43%, P < .001) than those residents without the disease. The use of trunk restraints was associated with higher risk for falls (adjusted odds ratio [AOR] = 1.66, P < .001) and fractures (AOR = 2.77, P < .01) among residents with the disease. The use of full bed rails was associated with lower risk for falls among residents with and without the disease (AOR = 0.67 and AOR = 0.72, Ps < .05, respectively). Conclusions: The use of a trunk restraint is associated with a higher risk for falls and fractures among residents with either AD or dementia.

We investigated the relationship between architectural space syntax measures describing the spatial layout of a home and activities of daily living (ADL) among people with dementia. We visited the homes of 82 participants in a dementia care comparative effectiveness clinical trial and measured the space syntax variables intelligibility and convexity along with several clinical variables, including ADLs. In regression models, we estimated the cross-sectional association between space syntax measures and ADLs. Higher convexity was associated with worse performance of basic but not instrumental ADLs (adjusted β =19.2, P = .02). Intelligibility was not associated with ADLs. These results imply that enclosed rooms with a clearly legible meaning and function might be better memorized and associated with the spatial layout of the home resulting in better basic ADL performance. These results warrant further research on space syntax measures in the home environment of people with dementia, including longitudinal study, which we are pursuing.

Background: One of the most difficult issues physicians must address when caring for persons with dementia is fitness to drive. The purpose of this project was to investigate the attitudes, knowledge, and practices of physicians toward drivers with dementia. Methods: A questionnaire that obtained perspectives about and experiences with drivers’ with dementia was mailed to physicians from North Carolina and South Carolina. Results: The sample was comprised of 239 physicians who worked with persons with dementia. Respondents who were aware of the Physician’s Guide to Assessing and Counseling Older Drivers, had a strong perceived role regarding driving, were older, and believed it was important to address driving were more likely to engage in driving discussions. Conclusions: Concerns associated with the driver with dementia have implications for not only patient care but also public safety. We recommend that all physicians be encouraged to address the issue and utilize existing educational materials.

Background: Rivastigmine patches provide similar efficacy to rivastigmine capsules with a lower incidence of gastrointestinal side effects in patients with probable Alzheimer’s disease (AD). Methods: Post hoc analysis of a 24-week, prospective, international, randomized, double-blind, placebo- and active-controlled trial. Patients (n = 892) with probable AD received rivastigmine transdermal patches (9.5 mg/24 hours [10 cm²]), rivastigmine capsules (6 mg twice daily), or placebo, and impact on activities of daily living (ADLs) was assessed utilizing 3 subscales: basic, high-level function, and autonomy. Results: At week 24, both rivastigmine groups demonstrated significantly superior performance in Alzheimer’s Disease Cooperative Study—Activities of Daily Living (ADCS-ADL) Total Score versus placebo (rivastigmine patch, P = .013; capsules, P = .039). Overall, both rivastigmine formulations provided benefits in ADL subscales. For basic ADLs, rivastigmine capsules performed significantly better than placebo (P = .012). For high-level function ADLs, rivastigmine patch performed better than placebo (P = .056). For autonomy ADLs, rivastigmine patch performed significantly better than placebo (P = .017). Conclusion: Rivastigmine patches and capsules provide significant effects in both total and subscale ADLs in patients with probable AD.

Background: Extrapyramidal signs (EPS) may vary across 3 major subtypes of primary progressive aphasia (PPA): progressive nonfluent aphasia (PNFA), semantic dementia (SD), and progressive logopenic aphasia (PLA). Methods: We reviewed initial neurological examinations from a clinical PPA cohort (PNFA = 49, SD = 26, PLA = 28) to determine the prevalence of specific categories of EPS. Results: The presence of any EPS was more common in PNFA (38.8%) and PLA (35.7%) than in SD (3.8%). The PNFA group exhibited the highest prevalence of bradykinesia (PNFA: 22.4%, SD: 3.8%, PLA: 0.0%) and rigidity (PNFA: 30.6%, SD: 0.0%, PLA: 10.7%). Calculated positive likelihood ratios indicated bradykinesia (12.1) or rigidity (5.5) was more strongly associated with PNFA than other PPAs. Conclusion: These findings suggest that on initial presentation, specific EPS may help distinguish PPA subtypes when linguistic and/or neuroimaging profiles are indistinct. Moreover, EPS could represent a marker of underlying tauopathy, linking clinical presentation to neuropathology in PPA.