Now is the Time to Improve Cognitive Screening and Assessment for Clinical and Research Advancement.

Wang et al. analyze Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment accuracy as screening tests for detecting dementia associated with Alzheimer's disease (AD). Such tests are at the center of controversy regarding recognition and treatment of AD. The continued widespread use of tools such as MMSE (1975) underscores the failure of advancing cognitive screening and assessment, which has hampered the development and evaluation of AD treatments. It is time to employ readily available, efficient computerized measures for population/mass screening, clinical assessment of dementia progression, and accurate determination of approaches for prevention and treatment of AD and related conditions.

Genetic Risk of Alzheimer's Disease: Three Wishes Now That the Genie is Out of the Bottle.

The availability and increasing popularity of direct-to-consumer genetic testing for the presence of an APOE4 allelle led the Alzheimer's Foundation of America Medical, Scientific and Memory Screening Advisory Board to identify three critical areas for attention: 1) ensure consumer understanding of test results; 2) address and limit potential negative consequences of acquiring this information; and 3) support linking results with positive health behaviors, including potential clinical trial participation. Improving access to appropriate sources of genetic counseling as part of the testing process is critical and requires action from clinicians and the genetic testing industry. Standardizing information and resources across the industry should start now, with the input of consumers and experts in genetic risk and health information disclosure. Direct-to-consumer testing companies and clinicians should assist consumers by facilitating consultation with genetic counselors and facilitating pursuit of accurate information about testing.

Engaging health care providers to improve the referral and evaluation processes for potential transplant candidates--The Toronto General Hospital Experience.

The Kidney Transplant Program (KTP) at the Toronto General Hospital has taken great strides in preparing to meet the needs of patients and health care providers, as the number of end-stage renal disease patients in Ontario increases. The KTP has begun the process of increasing engagement and collaboration with various stakeholders from the pre- to the post-transplant phase through (1) the development of innovative programs to increase the number of live kidney donations, (2) the development and maintenance of information technology solutions that work simultaneously to provide data to manage and treat patients, and conduct research, and (3) the development, implementation, and delivery of educational presentations and tools to various stakeholders both at the referring centres and the transplant program. Future steps for the KTP include evaluating the impact of these programmatic tools and activities on the number of referrals received and the subsequent effect on the number of transplants performed.

Cognitive Training Program to Improve Working Memory in Older Adults with MCI.

OBJECTIVES: Deficits in working memory (WM) are associated with age-related decline. We report findings from a clinical trial that examined the effectiveness of Cogmed, a computerized program that trains WM. We compare this program to a Sham condition in older adults with Mild Cognitive Impairment (MCI). METHODS: Older adults (N = 68) living in the community were assessed. Participants reported memory impairment and met criteria for MCI, either by poor delayed memory or poor performance in other cognitive areas. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS, Delayed Memory Index) and the Clinical Dementia Rating scale (CDR) were utilized. All presented with normal Mini Mental State Exams (MMSE) and activities of daily living (ADLs). Participants were randomized to Cogmed or a Sham computer program. Twenty-five sessions were completed over five to seven weeks. Pre, post, and follow-up measures included a battery of cognitive measures (three WM tests), a subjective memory scale, and a functional measure. RESULTS: Both intervention groups improved over time. Cogmed significantly outperformed Sham on Span Board and exceeded in subjective memory reports at follow-up as assessed by the Cognitive Failures Questionnaire (CFQ). The Cogmed group demonstrated better performance on the Functional Activities Questionnaire (FAQ), a measure of adjustment and far transfer, at follow-up. Both groups, especially Cogmed, enjoyed the intervention. CONCLUSIONS: Results suggest that WM was enhanced in both groups of older adults with MCI. Cogmed was better on one core WM measure and had higher ratings of satisfaction. The Sham condition declined on adjustment.

Randomized double-blind placebo trial of duloxetine in perioperative spine patients.

OBJECTIVE: This study describes a single-site investigation on the effects of a randomized double-blind placebo trial targeting duloxetine added to opioid use (duloxetine + opioid) against a comparator (placebo + opioid) in spine surgery patients, independent of major depression. DESIGN: The double-blind comparator study assessed two groups on opioids: one using duloxetine and the other a placebo. Subjects were administered the respective medication 2 weeks prior to surgery and continued on this for more than 3 months. Subjects were assessed at three times: prior to surgery, 4 weeks postsurgery, and 12 weeks postsurgery. They completed a battery of tests assessing for pain, adjustment, and psychiatric problems. SETTING: Neurosurgical outpatient and inpatient setting. PATIENTS: Sixty-eight patients completed the study. They received one of three types of elective spine surgery. INTERVENTIONS: Subjects were given duloxetine or placebo 2 weeks prior to surgery and continued with the regimen for more than 3 months. OUTCOMES: The primary focus was pain and second on adjustment factors and psychiatric symptoms: depression and anxiety. The amount of opioid use presurgery and postsurgery was also evaluated. RESULTS: There were differences among the groups on Brief Pain Inventory (BPI)-Average, the core pain marker, and BPI-Sleep. Within-subject analyses showed that duloxetine subjects improved significantly from baseline. For function, post-CIBIC and post-Functional Adjustment Questionnaire were significant, favoring duloxetine. Reduction of opioid use was not a factor; both groups' utilization declined. For affect, both groups were significantly improved over time. CONCLUSIONS: Duloxetine seems to improve pain, assist with maintaining function, and reduce intensity of affect.

Memory intervention: the value of a clinical holistic program for older adults with memory impairments.

OBJECTIVES: Increasingly, cognitive training appears an asset in improving attention and working memory for older adults. We conducted a study involving a 'holistic' training program for several cohorts of older adults (N = 112), targeting community residents with a spectrum of memory complaints ranging from Age Associated Memory Impairment to mild dementia. METHOD: We developed a 7-session, manualized program targeting concentration, as well as mindfulness, exercise, stress reduction, socialization, diet, and values/identity techniques. We applied this model to 11 cohorts and conducted pre- and post-testing on memory (List Learning, Story Memory, Coding, Digit Span, Recall, and Recognition) and function (Functional Assessment Questionnaire). We also divided the Memory Group by Risk Status - Low, Medium, and High. RESULTS: Results showed that the Memory Clinic Group as a whole improved on this training on most scales. When broken down by risk status, the Low and Medium Risk Groups were statistically superior to the High Risk Group on cognitive measures. CONCLUSION: There were differences also on adjustment, this time favoring only the Low Risk Groups. Holistic memory training seems to be impactful for older adults.

Treatment of insomnia in Parkinson's disease: a controlled trial of eszopiclone and placebo.

Parkinson's disease (PD) is a common neurodegenerative disease affecting up to 1 million individuals in the United States. Sleep disturbances, typically in sleep maintenance, are found in up to 88% of these individuals and are associated with a variety of poor outcomes. Despite being common and important, there are few data to guide clinical care. We conducted a 6-week, randomized, controlled trial of eszopiclone and placebo in 30 patients with PD and insomnia. Patients with other primary sleep disorders (PSG defined) were excluded. The primary outcome was total sleep time (TST), and secondary measures included wake after sleep onset (WASO), number of awakenings, and quality of sleep, among others. The groups did not significantly differ on TST, but significant differences, favoring eszopiclone, did emerge in number of awakenings (P = 0.035), quality of sleep (P = 0.018), and in physician-rated CGI improvement (P = 0.035). There was also a trend toward significance in WASO (P = 0.071). There were no significant differences between groups in measures of daytime functioning. The drug was well tolerated, with 33% of patients on eszopiclone and 27% of patients on placebo reporting adverse events. Although modest in size, this is the first controlled study of the treatment of insomnia in patients with PD. Eszopiclone did not increase TST significantly but was superior to placebo in improving quality of sleep and some measures of sleep maintenance, which is the most common sleep difficulty experienced by patients with PD. Definitive trials of the treatment of sleep disorders in this population are warranted.

Alzheimer's disease and vascular dementia: the complex relationship between diagnosis and caregiver burden.

The purpose of this study was to determine whether patient dementia diagnostic type (Alzheimer's Disease/Vascular Dementia) is associated with caregiver burden. A retrospective case review was conducted of patient and caregiver information collected at a university-based dementia clinic. Results showed that primary dementia diagnosis was not associated with burden. Rather, psychotic symptoms paired with poor IADL functioning generated the most burden, while cognitive dysfunction did not significantly influence burden. Additionally, caregiver gender (female), depressive symptoms, and being an adult child of the care recipient were associated with increased caregiver burden. Findings advocate for including tailored designs in caregiver interventions.

Group, individual, and staff therapy: an efficient and effective cognitive behavioral therapy in long-term care.

OBJECTIVE: Depression is a major problem in long-term care (LTC) as is the lack of related empirically supported psychological treatments. This small study addressed a variant of cognitive behavioral therapy, GIST (group, individual, and staff therapy), against treatment as usual (TAU) in long-term care. METHOD: 25 residents with depression were randomized to GIST (n = 13) or TAU (n = 12). Outcome measures included geriatric depression scale-short form (GDS-S), life satisfaction index Z (LSI-Z), and subjective ratings of treatment satisfaction. The GIST group participated in 15 group sessions. TAU crossed over to GIST at the end of the treatment trial. RESULTS: There were significant differences between GIST and TAU in favor of GIST on the GDS-S and LSI-Z. The GIST group maintained improvements over another 14 sessions. After crossover to GIST, TAU members showed significant improvement from baseline. Participants also reported high subjective ratings of treatment satisfaction. DISCUSSION: This trial demonstrated GIST to be more effective for depression in LTC than standard treatments.

Apathy in dementia: relations with depression, functional competence, and quality of life.

This study set out to clarify the association of apathy and depression in dementia as well as apathy's association with basic (ADLs) and instrumental (IADLs) activities of daily living and quality of life. 68 outpatients with mild dementia were assessed on apathy, depression, global cognition, traditional ADLs/IADLs, complex daily living activities requiring intact executive functioning (DAD: Disability Assessment for Dementia Scale), and quality of life. The sample was stratified into high and low global cognition groups and compared. While no relationship was found between scores on apathy and depression in the high cognition group, there was a significant relationship between apathy and depression in the low cognition group. Further, high and low cognition groups differed in the relationship between apathy and ability to perform basic and complex activities of daily living. Specifically, in the high cognition group, increased apathy was correlated with diminished ability to perform traditional IADLs as well as those activities requiring intact executive functioning (i.e., DAD). In the low cognition group, increased apathy was associated with poor performance on traditional ADLs and IADLs, but was not related to performance on independent daily activities demanding good executive functioning. Finally, increased apathy was significantly associated with worse quality of life, but this held for the high cognition group only, suggesting that dementia patients with better cognition have insight into their deficits and, perhaps, experience poor quality of life as a result.

Geropsychology:integrated training at the interim level.

The profession of psychology is responding to this culture's rapidly changing problems related to an aging population. A central theme regarding the training of clinical geropsychologists has been that education should be sequentially organized across levels, from undergraduate, to graduate, internship, postdoctoral, and continuing education for current practitioners. This paper addresses issues related to geropsychology training at the internship level. We address the need for such training and consider a generic model that outlines competency areas and activities that should be included in an internship program's geropsychology training component. We discuss further one model for implementing a multi-site, multi-level geropsychology training program, and consider issues the of recruiting, identifying training sites, and coordinating with other disciplines. We then consider future goals and plans.

Cognitive Testing Battery: differences among groups with dementia, Huntington's disease, and controls.

This study evaluated a new test for dementia, the Cognitive Testing Battery, used for over six years in outpatient clinics for aging-related disorders. This battery was developed to be brief, easy to administer, and to provide useful feedback as a cognitive profile for clinicians, patients, and caregivers. 489 participants were tested during a 5-yr. period. Multidisicplinary teams diagnosed these patients with dementia, depression, or Huntington's Disease. A control group was also included. Groups were then compared on the 10 key subscales that subserve dementia populations. Analysis showed there were significant differences among the groups on all measures and that selected scales differentiated the groups. The total score maximally differentiated the groups, and the dementia group was most different from the other groups.

The relationship between efficacy and methodology in studies investigating EMDR treatment of PTSD.

The controlled treatment outcome studies that examined the efficacy of EMDR in the treatment of posttraumatic stress disorder have yielded a range of results, with the efficacy of EMDR varying across studies. The current study sought to determine if differences in outcome were related to methodological differences. The research was reviewed to identify methodological strengths, weaknesses, and empirical findings. The relationships between effect size and methodology ratings were examined, using the Gold Standard (GS) Scale (adapted from Foa & Meadows, 1997). Results indicated a significant relationship between scores on the GS Scale and effect size, with more rigorous studies according to the GS Scale reporting larger effect sizes. There was also a significant correlation between effect size and treatment fidelity. Additional methodological components not detected by the GS Scale were identified, and suggestions were made for a Revised GS Scale. We conclude by noting that methodological rigor removes noise and thereby decreases error measurement, allowing for the more accurate detection of true treatment effects in EMDR studies.