August 14, 2014

American Journal of Alzheimer's Disease and Other Dementias June 2104

Full text articles are available to fee paying members of Alzheimer’s Australia NSW by emailing 

Adaptation to Early-Stage Nonfluent/Agrammatic Variant Primary Progressive Aphasia
A First-Person Account
Primary progressive aphasia (PPA) is a young-onset neurodegenerative disorder characterized by declining language ability. The nonfluent/agrammatic variant of PPA (PPA-G) has the core features of agrammatism in language production and effortful, halting speech. As with other frontotemporal spectrum disorders, there is currently no cure for PPA, nor is it possible to slow the course of progression. The primary goal of treatment is therefore palliative in nature. However, there is a paucity of published information about strategies to make meaningful improvements to the quality of life of people with PPA, particularly in the early stages of the disease where any benefit could most be appreciated by the affected person. This report describes a range of strategies and adaptations designed to improve the quality of life of a person with early-stage PPA-G, based on my experience under the care of a multidisciplinary medical team.
p. 289-292

Mild Cognitive Impairment
A Brief Review and Suggested Clinical Algorithm
Mild cognitive impairment (MCI) is a dynamic state between normal cognition and dementia, where interventions can be taken to stop or delay the progression to dementia. It is broadly of 2 types—amnestic, where memory loss is the chief concern and nonamnestic, where it is not. One variant of nonamnestic, dysexecutive, being more prevalent is sometimes known as a separate subtype by itself. Diagnosis of MCI is mostly clinical and is aided by various scales and neuropsychological testing. Functional imaging studies help in early detection and is superior to biomarkers or structural magnetic resonance imaging. Although there is no evidence supporting any pharmacological intervention, cognitive rehabilitation, memory training, and caregiver support play a strong role in limiting and sometimes reversing the ongoing cognitive decline. As the spectrum of MCI is heterogeneous, making the right diagnosis can be a challenging; hence, we need a systematic yet cost-effective algorithm for the timely management of MCI.
p. 293-302 

The Potential Role of Insulin on the Shank-Postsynaptic Platform in Neurodegenerative Diseases Involving Cognition
Loss of synaptic function is critical in the pathogenesis of Alzheimer’s disease (AD) and other central nervous system (CNS) degenerations. A promising candidate in the regulation of synaptic function is Shank, a protein that serves as a scaffold for excitatory synaptic receptors and proteins. Loss of Shank alters structure and function of the postsynaptic density (PSD). Shank proteins are associated with N-methyl-d-aspartate and α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor loss at the PSD in AD; mutations in Shank also lead to autism spectrum disorders (ASDs) and schizophrenia, both of which affect cognition, suggesting that Shank may play a common pathologic role in AD, ASD, and schizophrenia. Shank protein directly associates with insulin receptor substrate protein p53 in PSD. Insulin and insulin sensitizers have been used in clinical trials for these diseases; this suggests that insulin signals may alter protein homeostasis at the shank-postsynaptic platform in PSDs; insulin could improve the function of synapses in these diseases.
p. 303-310

Exploring the Influence of Environment on the Spatial Behavior of Older Adults in a Purpose-Built Acute Care Dementia Unit
Limited research explores the experience of individuals with dementia in acute care geriatric psychiatry units. This observational case study examines the influence of the physical environment on behavior (wandering, pacing, door testing, congregation and seclusions) among residents in a traditional geriatric psychiatry unit who were then relocated to a purpose-built acute care unit. Purpose-built environments should be well suited to the needs of residents with dementia. Observed trends revealed differences in spatial behaviors in the pre- and post- environments attributable to the physical environment. Person-centred modifications to the current environment including concerted efforts to know residents are meaningful in fostering quality of life. Color coded environments (rooms vs dining areas etc.) to improve wayfinding and opportunities to personalize rooms that address the `hominess' of the setting also have potential. Future research could also seek the opinions of staff about the impact of the environment on them as well as residents.
p. 311-319 

The Use of Visual Analog Scales to Compare Pain Between Patients With Alzheimer’s Disease and Patients Without Any Known Neurodegenerative Disease and Their Caregivers
Patients diagnosed with Alzheimer’s disease (AD) tend to underestimate their pain degree as disease progresses. Their caregivers are the most important source of information by providing regular pain evaluation. Our objectives were to compare pain intensity and affective pain between patients with AD and cognitively normal individuals (N) and to evaluate differences in pain perception between their caregivers. We evaluated pain scores of 121 patients with chronic osteoarticular pain, 60 AD, and 61 N using the colored pain scale/faces pain scale and the caregiver’s perception. Data were analyzed using one and two-tailed paired t tests (P < .05). We found that the AD group reported less pain intensity and that their pain was less perceived by their caregiver. This study also points to the need of, when evaluating patients with ADalways measure their pain degree using appropriate scales, instead of relying only on the caregiver.
p. 320-325
Basic Physical Capability Scale
Psychometric Testing With Cognitively Impaired Older Adults
The purpose of this study was to evaluate the reliability and validity of the Basic Physical Capability Scale when used with older adults having moderate to severe cognitive impairment and consider the utility of the measure in establishing function-focused care (FFC) goals for these individuals. The study was a secondary data analysis using data from 2 intervention studies testing FFC interventions in older adults with moderate to severe cognitive impairment in nursing homes and assisted living settings. Participants included 96 recruited from 4 assisted living facilities and 103 older adults from 4 nursing homes. There was support for validity of the measure based on construct validity and hypothesis testing, internal consistency (Cronbach's α of .79), and utility of the measure. Recommendations are provided for additional items that might help better differentiate individuals with moderate to severe cognitive impairment who are particularly high or low in basic physical capability.
p. 326-332 

Musical Training and Late-Life Cognition
This study investigated the effects of early- to midlife musical training on cognition in older adults. A musical training survey examined self-reported musical experience and objective knowledge in 237 cognitively intact participants. Responses were classified into low-, medium-, and high-knowledge groups. Linear mixed models compared the groups’ longitudinal performance on the Animal Naming Test (ANT; semantic verbal fluency) and Logical Memory Story A Immediate Recall (LMI; episodic memory) controlling for baseline age, time since baseline, education, sex, and full-scale IQ. Results indicate that high-knowledge participants had significantly higher LMI scores at baseline and over time compared to low-knowledge participants. The ANT scores did not differ among the groups. Ability to read music was associated with higher mean scores for both ANT and LMI over time. Early- to midlife musical training may be associated with improved late-life episodic and semantic memory as well as a useful marker of cognitive reserve.
p. 333-343 

Social Representation of Dementia and Its Influence on the Search for Early Care by Family Member Caregivers
Introduction: Social representations (SRs) contain 3 dimensions: information, attitude, and field. These affect the recognition of the first symptoms of dementia by the patient’s caregiver. This study focused on the period from the first signs of cognitive difficulties to the diagnosis of dementia.
Methods: Eight caregivers of elderly patients with dementia were interviewed to construct their SRs regarding dementia and how this influences seeking medical treatment during the first stages of the disease. Social representations were analyzed through a structural focus, based on the content analysis.
Results: Decision making is related to knowledge about dementia, attitude (emotions and sensitivity), and the concept of the caregiver about the relative with dementia. The results confirm the importance of the symbolic dimension of personal experience in managing care and seeking medical treatment.
Conclusion: The presence of dementia in the family creates interpersonal dilemmas that caregivers experience. The solutions are framed in the sociocultural context.
p. 344-353

Neuropsychiatric Symptoms in Patients With Alzheimer’s Disease
The Role of Caregiver Burden and Coping Strategies
This study was conducted to obtain data regarding the association of caregiver burden (CB) and neuropsychiatric symptoms (NPSs) in patients with Alzheimer’s disease. We conducted a series of multiple linear regressions to determine the relationship between CB and NPSs and whether the caregiver coping strategies mediated this relationship. The NPSs were assessed using the Neuropsychiatric Inventory, and caregivers were evaluated with the Caregiver Burden Interview and the Inventory and the Coping Strategies Inventory. Results show that patients with more frequent and severe NPS were more likely to be cared for by more burdened caregivers, and this was partially mediated by caregiver coping strategies. More disengagement (β = .330, P < .001) and less engagement coping (β = −.347, P < .001) were predictors for NPS after adjusting for patient and caregiver characteristics. These results may be useful with a view to designing treatment interventions that aim to modify the use of caregiver coping strategies and to reduce NPSs.
p. 354-361 

Functional Decline Predicts Emergency Department Use in Veterans With Dementia
Background: We examined emergency room (ER) utilization by persons with dementia (PWDs) using caregiver and patient characteristics as predictors.
Methods: A secondary analysis of 296 veteran–caregiver dyads. Caregivers recorded PWD baseline characteristics and noted ER visits over the next year. Two sets of regression models analyzed categorical ER use and repeat ER use.
Results: In the univariate analysis, categorical use of the ER was predicted by patients’ functional status (P ≤ .008) and Veterans Affairs priority grouping (P ≤ .02). Repeat ER admissions were predicted by functional status (P ≤ .04), number of chronic conditions (P ≤ .01), and caregiver-reported relationship strain (P ≤ .04). In multivariate analysis, categorical ER use was predicted by functional status (P ≤ .02), priority grouping (P ≤ .03), and number of chronic conditions (P ≤ .06).
Conclusions: Functional status most strongly predicted ER use, highlighting the promise of home-based interventions to improve activities of daily living. Number of chronic conditions and caregiver-reported relationship strain are potential targets of intervention during discharge process.
p. 362-371

The Impact of Exercise, Cognitive Activities, and Socialization on Cognitive Function
Results From the National Long-Term Care Survey
Currently, there are no effective treatments for Alzheimer’s disease and related disorders and age continues to be a robust risk factor. Thus, population aging in the United States may have catastrophic results if interventions are not found and implemented. This study examines possible associations between cognitive impairment and exercise, cognitive activities, and socialization. Cognitive activities, socialization, and exercise were assessed at baseline, and cognitive function was measured at baseline, 5-year, and 10-year follow-up. Controlling for baseline cognitive function, age, sex, education, diabetes, and hypertension, linear regression was performed. Engagement in cognitive activities was inversely associated with the onset of cognitive impairment at 5-year follow-up but was no longer significant at 10-year follow-up. Exercise was associated with a lower risk of cognitive impairment at 10-year follow-up but was not significant at 5-year follow-up. Associations with socialization were not statistically significant at either follow-up.
p. 372-378


An Exploratory Study of Grief and Health-Related Quality of Life for Caregivers of People With Dementia

The aim of this qualitative study was to explore key positive and negative factors that impact on grief resolution and health outcomes of caregivers who were caring, or had cared, for a family member with dementia who had died. The study was a scoping study and involved face-to-face interviews with these family caregivers (N = 13). Results indicated a complex interaction of issues (many unique to dementia caregiving) which in different combinations acted as protective or risk factors for caregiver outcomes. Interaction of individual characteristics, role appraisal, value of intrinsic and extrinsic resources, and experiences with health professionals during the caregiving period and around the death of their relative were shown to have the most influence on caregiver outcomes. Psychological resilience and satisfaction with caregiving were protective against negative outcomes while unresolved grief was a risk factor. These findings highlight the potential benefits of multicomponent, holistic dementia caregiver interventions.

p. 379-385


Reactions and Interventions for Delusions in Nursing Home Residents with Dementia

This is a qualitative and quantitative study examining institutional staff members’ reactions to delusions experienced by nursing home residents. Participants were 38 nursing home residents aged 65 and older, diagnosed with dementia. Data were collected from 8 nursing homes in Israel between June 2007 and January 2009. Assessments included Behavioral Pathology in Alzheimer’s Disease Rating Scale, Neuropsychiatric Inventory: Nursing Home version, Etiological Assessment of Psychotic Symptoms In Dementia, Activities of Daily Living, and Mini-Mental State Examination. A wide variety of interventions with dementia-related symptoms was found to be effective to varying degrees. This included general approaches for a variety of symptoms as well as symptom-specific interventions. Caregivers do not always seem to be aware that multiple approaches are available to them when dealing with dementia. The most effective approaches may be those tailored to the individual. Combining interventions may increase overall effectiveness. Caregiver’s experience and the institutional culture may affect the choice of intervention used, either positively or negatively.

p. 386-394

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