Cognitive rehabilitation for early stage Alzheimer's disease: a pilot study with an Irish population.

OBJECTIVES: Research shows that cognitive rehabilitation (CR) has the potential to improve goal performance and enhance well-being for people with early stage Alzheimer's disease (AD). This single subject, multiple baseline design (MBD) research investigated the clinical efficacy of an 8-week individualised CR intervention for individuals with early stage AD. METHODS: Three participants with early stage AD were recruited to take part in the study. The intervention consisted of eight sessions of 60-90 minutes of CR. Outcomes included goal performance and satisfaction, quality of life, cognitive and everyday functioning, mood, and memory self-efficacy for participants with AD; and carer burden, general mental health, quality of life, and mood of carers. RESULTS: Visual analysis of MBD data demonstrated a functional relationship between CR and improvements in participants' goal performance. Subjective ratings of goal performance and satisfaction increased from baseline to post-test for three participants and were maintained at follow-up for two. Baseline to post-test quality of life scores improved for three participants, whereas cognitive function and memory self-efficacy scores improved for two. CONCLUSIONS: Our findings demonstrate that CR can improve goal performance, and is a socially acceptable intervention that can be implemented by practitioners with assistance from carers between sessions. This study represents one of the promising first step towards filling a practice gap in this area. Further research and randomised-controlled trials are required.

The National Single Assessment Tool (SAT) a pilot study in older persons care-survey results.

Following a consultation and review process, the interRAI suite of assessment tools was chosen as the most suitable instrument for assessment of the care needs of older people in Ireland. We used previously validated questionnaires to examine the usability, practicality and acceptability of these tools to professionals, carers and clients in rural and urban acute, long-term care and community settings. Of the 45 professionals, 42-44 (93-98%) agreed or strongly agreed with 14 of 15 positive statements regarding the acceptability, clinical value and ease of use of the interRAl tools; 39 (87%) felt the terminology was consistent and familiar, although 35 (78%) felt some areas would require further explanation. Responses from carers (n = 15) and clients (n = 68) were similarly overwhelmingly positive regarding the experience of being assessed using these tools. These results support the clinical utility and practicality of using this approach to assess older people in Irish clinical practice.

Assessment of behavioural markers of autonoetic consciousness during episodic autobiographical memory retrieval: a preliminary analysis.

There is ongoing theoretical debate regarding episodic memory and how it can be accurately measured, in particular if the focus should be content-based recall of episodic details or something more experiential involving the subjective capacity to mentally travel back in time and "re-live" aspects of the original event. The autonoetic subscale of the Episodic Autobiographical Memory Interview (EAMI) is presented here as a new test instrument that attempts to redress theoretical and methodological shortcomings in autobiographical memory assessment. The EAMI merges a phenomenological detail-based approach with an assessment of autonoetic consciousness, departing considerably from traditional Remember/Know paradigms used within this field. We present findings from an initial pilot study investigating the potential markers of autonoetic consciousness that may accompany episodic retrieval. Key behavioural indices of autonoetic consciousness, notably those of viewer perspective, visual imagery, and emotional re-experiencing, emerged as being inextricably bound with the level of phenomenological detail recalled and the overall re-living judgment. The autonoetic subscale of the EAMI permits conceptually refined assessment of episodic personal memories and the accompanying subjective experience of mental re-living, characteristic of episodic memory.

Health-related quality of life of stroke survivors attending the volunteer stroke scheme.

BACKGROUND: The Volunteer Stroke Scheme (VSS) provides patients with the opportunity to participate in community-based therapeutic activities and physiotherapy sessions. AIMS: To provide the first profile of VSS attendees in terms of their functioning across the range of recommended WHO International Classification of Functioning, Disability and Health (ICF) outcomes. METHODS: A convenience sample of 41 VSS patients completed standardised measures of cognitive functioning (MMSE), activity levels [Frenchay Activity Index (FAI), and Barthel Index (BI)], depression [Hospital Anxiety and Depression Scale (HADS)] and Quality of Life (SF-36). RESULTS: A total of 37% met the criteria for mild cognitive impairment and 44% met the criteria for clinical depression. Scores on the BI (M = 79.5) and FAI (M = 18.4) incidated limitations in activity levels. Quality of life levels was low. CONCLUSIONS: High levels of psychological morbidity, severe disability across a range of domains and poor quality of life were reported.

The attitudes and practices of general practitioners regarding dementia diagnosis in Ireland.

BACKGROUND: The diagnosis of dementia poses difficulties for general practitioners (GPs) particularly when access to specialist diagnostic services is delayed. Ireland is soon to witness an increase in numbers of people presenting with dementia, yet little is known about the service needs of GPs when attempting to diagnose dementia. OBJECTIVES: To detail the service needs of GPs, especially their training needs, access to diagnostic resources such as CT and MRI brain scans and access to specialist services such as Old Age Psychiatry (OAP), Geriatric Medicine (GM) and Neuropsychology (NP). METHODS: The paper is based on survey data collected from a sample of GPs (n = 300) registered with the Irish College of General Practitioners (ICGP) and on qualitative data collected from a Focus Group (n = 7). RESULTS: GPs were more likely to blame themselves than either the health care system, their patients or family members for the late presentation of dementia in primary care. Stigma was a major obstacle preventing GPs from being more proactive in this area. Rural GPs felt geographically disadvantaged accessing diagnostic services and both rural and urban GPs experienced considerable time delays accessing specialist diagnostic services. CONCLUSIONS: Findings provide compelling evidence that training and access to diagnostic services are only two of several different structural and ideological obstacles that GPs encounter when attempting to diagnose dementia. Future educational supports for GPs need to be developed which concentrate on these areas.

Loss of insight in frontotemporal dementia, corticobasal degeneration and progressive supranuclear palsy.

Loss of insight is one of the core features of frontal/behavioural variant frontotemporal dementia (FTD). FTD shares many clinical and pathological features with corticobasal degeneration (CBD) and progressive supranuclear palsy (PSP). The aim of this study was to investigate awareness of cognitive deficits in FTD, CBD and PSP using a multidimensional approach to assessment, which examines metacognitive knowledge of the disorders, online monitoring of errors (emergent awareness) and ability to accurately predict performance on future tasks (anticipatory awareness). Thirty-five patients (14 FTD, 11 CBD and 10 PSP) and 20 controls were recruited. Results indicated that loss of insight was a feature of each of the three patient groups. FTD patients were most impaired on online monitoring of errors compared to the other two patient groups. Linear regression analysis demonstrated that different patterns of neuropsychological performance and behavioural rating scores predicted insight deficits across the three putative awareness categories. Furthermore, higher levels of depression were associated with poor anticipatory awareness, reduced empathy was related to impaired metacognitive awareness and impaired recognition of emotional expression in faces was associated with both metacognitive and anticipatory awareness deficits. The results are discussed in terms of neurocognitive models of awareness and different patterns of neurobiological decline in the separate patient groups.

The clinical dementia rating sum of box score in mild dementia.

BACKGROUND: Making an early diagnosis of dementia is becoming increasingly important, but is difficult in practice. The Clinical Dementia Rating (CDR) scale is a widely used dementia staging instrument, yielding a global score and a summated score (sum of box score). This study examines the utility of the CDR sum of box score, rather than the CDR global score, in making a diagnosis of early dementia. OBJECTIVE: To determine whether the CDR sum of box score is predictive of an ICD-10 diagnosis of dementia in cases with mild cognitive deficits. METHODS: Clinical data recorded on our Memory Clinic database were examined for all patients seen over a 6-year period. Data were extracted from 276 first visits in which patients had scored 0.5 using the CDR global score. We examined the relationship between CDR sum of box score and consensus diagnosis of dementia using logistic regression. RESULTS: We found that increased CDR sum of box score was significantly associated with a higher probability of being assigned an ICD-10 diagnosis of dementia (p < 0.001). The odds ratio for the coefficient of CDR sum of box was 2.3 (95% CI 1.7-3.1), indicating that the likelihood of being diagnosed as having dementia increased by a factor of 2.3 for every point increase on the CDR sum of box score. CONCLUSION: These findings indicate that the CDR sum of box score provides additional information to the CDR global score in mild cases. The CDR sum of box score is a helpful indicator in making/excluding a diagnosis of dementia in people with mild cognitive deficits.

Syndromes of behavioural and psychological symptoms in mild Alzheimer's disease.

OBJECTIVES: Behavioural and psychological symptoms of dementia (BPSD) are common in Alzheimer's disease (AD), and are associated with significant distress for patient and carer. Certain behavioural and psychological symptoms have been associated with each other, leading to the suggestion that differences in symptom patterns among patients with AD may represent different syndromes within AD. The purpose of this study is to see if patients with AD could be meaningfully classified into syndromes, based on the relationships between their BPSD. METHODOLOGY: The sample was recruited through a memory clinic. Two hundred and forty first visit patients with a diagnosis of very mild to mild AD were included. BPSD were assessed using the BEHAVE-AD. Latent class analysis was used to assess for different classes or groups of patients within the sample, based on their behavioural and psychological symptoms. RESULTS: Three classes were identified; Class 1 with a low prevalence of behavioural and psychological symptoms; Class 2 an anxiety/depressive symptom class and Class 3 an aggressive symptom class. CONCLUSIONS: The three classes (or groups) of patients obtained by LCA in this sample may be explained by a 'latent', as yet, unidentified factor. Further research is required to determine if these classes are stable over time, and to identify possible latent variables.

Endogenous sex hormone levels in postmenopausal women with Alzheimer's disease.

A cross-sectional study examined whether there was a difference in endogenous serum sex hormone levels between community-dwelling postmenopausal women with Alzheimer's disease (AD) and healthy controls. Total morning levels of serum estrone, estradiol, androstenedione, testosterone, and cortisol were measured in 52 nondepressed women with AD and 60 postmenopausal women who were neither depressed nor cognitively impaired. Estradiol was undetectable in 35.7% of cases, but detectable hormone was found in 96-100% of cases otherwise. After adjustment for potential confounds, serum levels were significantly higher for estrone (P = 0.0057) and androstenedione (P = 0.02), but not testosterone (P = 0.086) or estradiol (P = 0.59), in subjects with AD. Sex hormone levels did not correlate with cognitive scores in either group. Although the failure to detect estradiol in a third of cases limits the conclusions that can be drawn for this hormone, the possibility that AD is associated with abnormalities in certain serum sex hormone levels should be considered and warrants further research.

Prognostic value of electrophysiological markers in Alzheimer's disease.

The authors assessed the usefulness of event-related potentials (ERP) and flash visual evoked potentials (FVEP) as prognostic markers in a sample of 25 subjects with probable Alzheimer's disease (AD). ERP and FVEP recordings were obtained from 21 and 23 subjects, respectively. Ranking of the annual rate of change in cognitive scales vs. baseline ERP/FVEP latencies was compared, and those with longer FVEP N(2) component latencies showed slower subsequent rates of decline (tau=0.32; z=2.16; P=0.015), suggesting that further study of FVEP responses as prognostic markers in AD is warranted.

The association between demographic factors, disease severity and the duration of symptoms at clinical presentation in elderly people with dementia.

OBJECTIVE: To determine the association between factors unrelated to the disease process, the duration of symptoms and the degree of cognitive or functional impairment in elderly patients presenting with dementia. METHOD: The living situation, educational level, age, gender and diagnosis based on standardized criteria were recorded for 209 elderly patients presenting to a memory clinic with dementia. Cognitive and functional deficits were measured with the cognitive section of the Cambridge Mental Disorders of the Elderly Examination combined with the Mini-Mental State Examination and the abbreviated version of the Blessed dementia scale, respectively. RESULTS: 129 patients had a diagnosis of probable Alzheimer's disease, 19 had probable ischaemic vascular dementia and 61 had mixed dementia. There was no effect of diagnosis on duration of symptoms or dementia severity at the time of presentation. Patients living with a son or daughter were more functionally impaired than those living alone or with a spouse. Males had higher cognitive scores but did not have milder functional deficits. Patients with only a primary-school education had a trend towards lower cognitive scores at presentation but did not have more functional deficits. CONCLUSIONS: The gender of the patient and the relationship to the carer are associated with cognitive and functional scores at the time of presentation in patients with dementia.

Dementia carer education and patient behaviour disturbance.

OBJECTIVE: To evaluate the impact of a dementia Carer Education Programme on carer quality of life (QoL), burden, and well-being. DESIGN: Single group before-after intervention study. The group was subdivided by perceived status post-programme for intragroup analysis. SETTING: Hospital memory clinic. PARTICIPANTS: Convenience sample of 32 dementia carers. INTERVENTION: Eight weekly 2 h education and support sessions run by a psychogeriatric clinical team. MEASURES: Pre-programme and 6 months post-programme data were obtained. Measures included individually perceived QoL, burden, well-being, managing problem behaviour, appraisal of social support, knowledge of dementia, and perception of the programme. Patients were characterized in terms of cognition, behaviour disturbance and functional status. RESULTS: Twelve carers reported their situation post-programme as 'better', 12 as 'worse', and four as 'no change'. There were no significant baseline differences. For 'better/no change' carers the only significant change over time was increased knowledge about dementia. For 'worse' carers knowledge also increased, but there was evidence of poorer QoL, increased burden, a poorer appraisal of social support, and increased patient behaviour disturbance. Only patient behaviour disturbance significantly discriminated 'no change/better' from 'worse' carers (F = 4.08, p = 0.055). CONCLUSIONS: The programme increased carers' knowledge about dementia, but had no significant impact on QoL, burden, or well-being. Increased patient behaviour disturbance appeared to be a major factor when the carer's situation worsened over time. Despite high carer satisfaction the efficacy of a group-based education approach to the management of behaviour disturbance in dementia appears limited. More intensive or individually tailored interventions may be necessary alternatives.

Assessment of progression and prognosis in 'possible' and 'probable' Alzheimer's disease.

OBJECTIVE: The objective of this study was to assess the rate of progression and clinical predictors of decline in subjects with possible and probable Alzheimer's disease (AD). DESIGN/SETTING: The annual rate of change (ARC) for cognitive/functional scales was calculated for 95 subjects with AD attending a memory clinic. Two consecutive ARCs were calculated for a subgroup of 39 subjects. RESULTS: The ARCs were relatively normally distributed; however, there was a large degree of variability. Neither age nor duration of symptoms at presentations were predictive of the rate of decline. However, the data suggested an effect of gender, with males having a greater rate of decline in cognition (p = 0.02). Finally, the rate of progression over the first year did not predict the subsequent ARC (p = 0.25). CONCLUSIONS: The high variability in ARCs observed in this study and poor correlation between consecutive ARCs suggest that neither mean ARC values nor the previous rate of decline can be used to aid clinicians in the assessment of response to acetylcholinesterase inhibitors or other specific treatments for AD.

Hypothalamic-pituitary-adrenal axis dysfunction in Alzheimer's disease: lack of association between longitudinal and cross-sectional findings.

OBJECTIVE: The authors examined longitudinal hypothalamic-pituitary-adrenal (HPA) axis function in Alzheimer's disease. METHOD: Cortisol levels of 30 patients with Alzheimer's disease and 17 healthy elderly subjects were measured before and after administration of dexamethasone. These measures were repeated at 9-month intervals in the patients with Alzheimer's disease. RESULTS: At baseline, cortisol levels were higher in the Alzheimer's disease group before and after dexamethasone administration. Although only two of the four patients whose cortisol levels were not suppressed by dexamethasone also had high cortisol levels before dexamethasone administration, basal and postdexamethasone cortisol levels were correlated. HPA axis dysfunction correlated with severity of dementia at baseline but was not stable longitudinally and did not increase with follow-up. CONCLUSIONS: There was no association between longitudinal and cross-sectional findings. The longitudinal data were not consistent with a role for the glucocorticoid cascade hypothesis (that hippocampal cell loss in Alzheimer's disease results in hypercortisolism, which in turn acts as a co-factor in further degeneration) in the pathophysiology of mild and moderate Alzheimer's disease.

Distinguishing between patients with depression or very mild Alzheimer's disease using the Delayed-Word-Recall test.

The present study investigated the accuracy of an extended version of the Delayed Word Recall (DWR) test in distinguishing patients with very mild Alzheimer's disease (AD) (Mini Mental State Examination score > or = 23) from community-dwelling depressed/dysthymic patients. The DWR test was administered to 26 non-depressed patients who, at the time of DWR administration or on follow-up, fulfilled NINCDS/ADRDA criteria for probable AD, and to 20 age-matched non-dementing patients with a diagnosis of major depression (n = 12) or dysthymia (n = 8) according to DSM-III-R criteria. Sensitivity and specificity were, respectively, 96 and 100% for DWR free recall, and 92 and 100% for DWR recognition. In this study both DWR free recall and recognition measures were highly sensitive and specific in distinguishing very-mild-AD patients from depressed/dysthymic patients. The investigation of more severely depressed patients is warranted.

Behaviour disturbance and other predictors of carer burden in Alzheimer's disease.

OBJECTIVE: To investigate predictors of carer burden in Alzheimer's disease (AD). DESIGN: Two cohorts were formed, one comprising AD patients, the other comprising their primary carers. The relationship of patient and carer variables to carer burden was investigated. SETTING: An urban hospital memory clinic. PARTICIPANTS: A convenience sample of 50 patients meeting NINCDS-ADRDA for probable AD, age range 60-87, and their primary carers, age range 31-84. MEASURES: The Cambridge Cognitive Examination (CAMCOG), the Mini-Mental State Examination (MMSE), the Baumgarten et al. Dementia Behaviour Disturbance Scale, the Blessed-Roth Dementia Scale, the Personal Self-Maintenance Scale, the Zarit Burden Interview and the Vaux et al. Social Support Appraisals (SS-A) and Social Support Behaviours (SS-B) Scales. RESULTS: Daughters were particularly prone to burden. Neither patient cognitive nor functional status predicted burden. Behaviour disturbance in particular, and informal support were significant, but independent, predictors of carer burden. CONCLUSIONS: In this study increased carer burden was related independently to increased levels of patient behaviour disturbance and decreased levels of informal social support. This may have relevance to appropriate interventions for carers. As the study was based on a convenience sample of memory clinic attenders, replication in less highly selected samples is desirable.

Utility of ischemic scores in the differential diagnosis of Alzheimer's disease and ischemic vascular dementia.

Despite new developments in the concept of vascular dementia, the Hachinski Ischemic Score (HIS) and its modified versions continue to be widely used in the clinical differentiation of Alzheimer's disease (AD) and ischemic vascular dementia (IVD). The sensitivity of the HIS and two modified versions in the diagnosis of AD, IVD, and single infarcts in a large, geriatric population with mild cognitive impairment (N = 100) was evaluated. Sensitivity for identification of AD was greater than 90% but was less than 70% for IVD. Over one third of patients with one or more infarcts on computed tomographic brain scans and 63% of mixed cases were classified as having probable AD. It is concluded that ischemic scores may be useful at predicting prevalence rates if individual case accuracy is ignored. Despite being sensitive to identifying AD, ischemic scores are insensitive to both cerebral infarction and IVD and cannot reliably exclude IVD. Finally, patients with mixed dementia should not be expected to have intermediate scores.