Predictors of the importance of everyday preferences for older adults with cognitive impairment.

OBJECTIVES: Among older people with cognitive impairment and mild dementia, relatively little is known about the factors that predict preferences for everyday living activities and experiences and that influence the relative importance of those activities and experiences. DESIGN: Cross-sectional study. SETTING: Participants were recruited from the Massachusetts Alzheimer's Disease Research Center (MADRC) Clinical Core longitudinal cohort. PARTICIPANTS: The sample included 62 community-dwelling older adults with cognitive impairment (Clinical Dementia Rating global score ≥ 0.5). MEASUREMENTS: We used the Preferences for Everyday Living Inventory (PELI) to assess preferences for activities and lifestyle experiences among persons with cognitive impairment. Within-subjects analysis of variance was used to test for significant differences in the mean ratings of importance for four domains of the PELI ("autonomous choice," "social engagement," "personal growth," and "keeping a routine"). Multiple regression models were used to relate predictors, including neuropsychiatric symptoms, to importance ratings for each domain. RESULTS: Significant differences were noted in the mean importance ratings of the preferences domains: "social engagement" preferences were rated as most important, followed by "autonomous choice," "personal growth," and "keeping a routine." For the "social engagement" preferences domain, female sex was significantly associated with higher importance of "social engagement," while depressive symptoms (Geriatric Depression Scale-15 scores) were significantly associated with lower importance. CONCLUSIONS: This study adds novel insight into the everyday preferences of community-dwelling older adults with cognitive impairment and highlights the impact of a number of factors, particularly level of depression, on how important various everyday experiences are perceived.

Differences in Assessment of Everyday Preferences Between People With Cognitive Impairment and Their Care Partners: The Role of Neuropsychiatric Symptoms.

OBJECTIVE: As cognitive impairment progresses, people with dementia increasingly rely on surrogate decision-makers for everyday activities. Yet, little is known about concordance on everyday preferences between persons with cognitive impairment and their care partners. METHODS: The sample included 69 dyads of persons with cognitive impairment (Clinical Dementia Rating Scale ≥0.5) and their care partners. We used the Preferences for Everyday Living Inventory (PELI) to assess preferences for activities and lifestyle choices among persons with cognitive impairment. The PELI was concurrently but separately administered to care partners, who answered as surrogate decision-makers. Factor analysis was used to ascertain factor structure of the PELI; reliability measures were computed within the sample. Paired sample t-tests were used to estimate differences in scores of corresponding PELI items for each factor. Multiple regression models were used to relate predictors, including neuropsychiatric symptoms, to agreement levels. RESULTS: Four factors were identified from the PELI: autonomous choice, social engagement, personal growth, and keeping a routine. Significant participant-care partner discrepancy was found in "social engagement" preferences (e.g., regular contact with family, meeting new people, volunteering). Geriatric Depression Scale-15 score and care partner sex were significantly associated with participant-care partner discrepancies in "social engagement" preferences. CONCLUSION: This study yields new insights regarding the most important preferences for persons with cognitive impairment and clarifies a path to optimizing surrogate decision-making around everyday preferences by highlighting areas of apparent disagreement and identifying potential predictors of discrepancy.

Adverse outcomes after hospitalization and delirium in persons with Alzheimer disease.

BACKGROUND: Hospitalization, frequently complicated by delirium, can be a life-changing event for patients with Alzheimer disease (AD). OBJECTIVE: To determine risks for institutionalization, cognitive decline, or death associated with hospitalization and delirium in patients with AD. DESIGN: Prospective cohort enrolled between 1991 and 2006 into the Massachusetts Alzheimer's Disease Research Center (MADRC) patient registry. SETTING: Community-based. PARTICIPANTS: 771 persons aged 65 years or older with a clinical diagnosis of AD. MEASUREMENTS: Hospitalization, delirium, death, and institutionalization were identified through administrative databases. Cognitive decline was defined as a decrease of 4 or more points on the Blessed Information-Memory-Concentration test score. Multivariate analysis was used to calculate adjusted relative risks (RRs). RESULTS: Of 771 participants with AD, 367 (48%) were hospitalized and 194 (25%) developed delirium. Hospitalized patients who did not have delirium had an increased risk for death (adjusted RR, 4.7 [95% CI, 1.9 to 11.6]) and institutionalization (adjusted RR, 6.9 [CI, 4.0 to 11.7]). With delirium, risk for death (adjusted RR, 5.4 [CI, 2.3 to 12.5]) and institutionalization (adjusted RR, 9.3 [CI, 5.5 to 15.7]) increased further. With hospitalization and delirium, the adjusted RR for cognitive decline for patients with AD was 1.6 (CI, 1.2 to 2.3). Among hospitalized patients with AD, 21% of the incidences of cognitive decline, 15% of institutionalization, and 6% of deaths were associated with delirium. LIMITATIONS: Cognitive outcome was missing in 291 patients. Sensitivity analysis was performed to test the effect of missing data, and a composite outcome was used to decrease the effect of missing data. CONCLUSION: Approximately 1 in 8 hospitalized patients with AD who develop delirium will have at least 1 adverse outcome, including death, institutionalization, or cognitive decline, associated with delirium. Delirium prevention may represent an important strategy for reducing adverse outcomes in this population.

Delirium and Long-term Cognitive Trajectory Among Persons With Dementia.

BACKGROUND Delirium is characterized by acute cognitive impairment. We examined the association of delirium with long-term cognitive trajectories in older adults with Alzheimer disease (AD). METHODS We evaluated prospectively collected data from a nested cohort of hospitalized patients with AD (n = 263) in the Massachusetts Alzheimer Disease Research Center patient registry between January 1, 1991, and June 30, 2006 (median follow-up duration, 3.2 years). Cognitive function was measured using the information-memory-concentration (IMC) section of the Blessed Dementia Rating Scale. Delirium was identified using a validated medical record review method. The rate of cognitive deterioration was contrasted using random-effects regression models. RESULTS Fifty-six percent of patients with AD developed delirium during hospitalization. The rate of cognitive deterioration before hospitalization did not differ significantly between patients who developed delirium (1.4 [95% CI, 0.7-2.1] IMC points per year) and patients who did not develop delirium (0.8 [95% CI, 0.3-1.3] IMC points per year) (P = .24). After adjusting for dementia severity, comorbidity, and demographic characteristics, patients who had developed delirium experienced greater cognitive deterioration in the year following hospitalization (3.1 [95% CI, 2.1-4.1] IMC points per year) relative to patients who had not developed delirium (1.4 [95% CI, 0.2-2.6] IMC points per year). The ratio of these changes suggests that cognitive deterioration following delirium proceeds at twice the rate in the year after hospitalization compared with patients who did not develop delirium. Patients who had developed delirium maintained a more rapid rate of cognitive deterioration throughout a 5-year period following hospitalization. Sensitivity analyses that excluded rehospitalized patients and included matching on baseline cognitive function and baseline rate of cognitive deterioration produced essentially identical results. CONCLUSIONS Delirium is highly prevalent among persons with AD who are hospitalized and is associated with an increased rate of cognitive deterioration that is maintained for up to 5 years. Strategies to prevent delirium may represent a promising avenue to explore for ameliorating cognitive deterioration in AD.

Assessing depression and factors possibly associated with depression during the course of Parkinson's disease.

BACKGROUND: Although research suggests depression is common among individuals with Parkinson's disease (PD), it is unclear how to best assess depression in PD (dPD). We wanted to examine the prevalence of dPD using different definitions of depression, as well as examine factors associated with dPD. METHODS: One hundred fifty-eight individuals (68% male; age 66.8 ± 9.6 SD) with a primary diagnosis of PD were assessed for depression using the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS) in an outpatient setting at the Movement Disorders Clinic at Massachusetts General Hospital. We defined depression using 4 thresholds based on the HANDS and whether or not an individual was ever on an antidepressant regimen. We also examined potential predictors of the presence of dPD. RESULTS: The prevalence of depression among study participants ranged from 11% to 57%, depending on which of the 4 definitions of depression was applied. Younger age and longer duration of PD predicted a relatively higher prevalence of depression. Having a history of depression prior to onset of PD also was predictive of dPD. CONCLUSIONS: Depression appears to be relatively common among individuals with PD, and history of depression, younger age, and longer PD duration may be factors associated with dPD.

Hospitalization in community-dwelling persons with Alzheimer's disease: frequency and causes.

OBJECTIVES: To examine the rates of and risk factors for acute hospitalization in a prospective cohort of older community-dwelling patients with Alzheimer's disease (AD). DESIGN: Longitudinal patient registry. SETTING: AD research center. PARTICIPANTS: Eight hundred twenty-seven older persons with AD. MEASUREMENTS: Acute hospitalization after AD research center visit was determined from a Medicare database. Risk factor variables included demographics, dementia-related, comorbidity and diagnoses and were measured in interviews and according to Medicare data. RESULTS: Of the 827 eligible patients seen at the ADRC during 1991 to 2006 (median follow-up 3.0 years), 542 (66%) were hospitalized at least once, and 389 (47%) were hospitalized two or more times, with a median of 3 days spent in the hospital per person-year. Leading reasons for admission were syncope or falls (26%), ischemic heart disease (17%), gastrointestinal disease (9%), pneumonia (6%), and delirium (5%). Five significant independent risk factors for hospitalization were higher comorbidity (hazard ratio (HR)=1.87, 95% confidence interval (CI)=1.57-2.23), previous acute hospitalization (HR=1.65, 95% CI=1.37-1.99), older age (HR=1.51, 95% CI=1.26-1.81), male sex (HR=1.27, 95% CI=1.04-1.54), and shorter duration of dementia symptoms (HR=1.26, 95% CI=1.02-1.56). Cumulative risk of hospitalization increased with number of risk factors present at baseline: 38% with zero factors, 57% with one factor, 70% with two or three factors, and 85% with four or five factors (P(trend) <.001). CONCLUSION: In a community-dwelling population with generally mild AD, hospitalization is frequent, occurring in two-thirds of participants over a median follow-up time of 3 years. With these results, clinicians may be able to identify dementia patients at high risk for hospitalization.

Cognitive-behavioral therapy for patients with Parkinson's disease and comorbid major depressive disorder.

BACKGROUND: Depression has been recognized as a common feature of Parkinson's disease (PD), and is the most prevalent psychiatric disorder in PD patients. OBJECTIVE: The authors sought to determine whether cognitive-behavioral therapy (CBT) is effective in the treatment of depression within the context of PD (dPD). METHOD: The authors enrolled 8 depressed PD patients into an open treatment study of 12 weeks of individual CBT treatment. RESULTS: There was a significant linear decrease in mean Hamilton Rating Scale for Depression (17-item) scores over Weeks 0 to 12, and 57% of patients (4/7) met criteria for remission at endpoint. CONCLUSION: This uncontrolled study suggests that CBT may be effective in treating dPD and may be an alternative or adjunct to pharmacological treatment.

Pattern of depressive symptoms in Parkinson's disease.

BACKGROUND: Depressive symptoms are common in Parkinson's disease (PD); however, it is unclear whether there are specific depressive symptom patterns in patients with PD and comorbid depression (dPD). OBJECTIVE: The goal of this study is to examine the frequency and correlates of specific depressive symptoms in PD. METHOD: A sample of 158 individuals with PD completed the self-rated Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS). By multiple-regression analysis, the authors examined the association between HANDS total and subscale scores and various demographic variables. RESULTS: The frequency of depression was 37% (N=58). Patients with a history of depression before PD had significantly more serious depression than those who had no such history. Of those who were more depressed, the most common symptoms of depression endorsed were low energy, difficulty with concentration/making decisions, feeling blue, feeling hopeless, and having poor sleep. CONCLUSION: There is a relatively high prevalence of dPD. Items on the HANDS that discriminated best between depressed and nondepressed subjects with PD included feeling blue, feeling hopeless, feeling worthless, lack of interest, and self-blame. It remains to be defined whether dPD should be understood primarily as a psychological reaction to a physical disability or perceived impending one, or as a direct expression of the neuropathology of PD.

Plasma amyloid beta-protein and C-reactive protein in relation to the rate of progression of Alzheimer disease.

OBJECTIVE: To examine whether plasma markers of amyloid precursor protein metabolism (amyloid beta-protein ending in Val-40 [Abeta40] and Ala-42 [Abeta42]), inflammation (high-sensitivity C-reactive protein), and folic acid metabolism (folic acid, vitamin B(12), and total homocysteine levels) are associated with the rate of cognitive and functional decline in persons with Alzheimer disease. DESIGN: Longitudinal study across a mean (SD) of 4.2 (2.6) years with assessments at approximately 6- to 12-month intervals. SETTING: Outpatient care. PATIENTS: A cohort of 122 patients having a clinical diagnosis of probable Alzheimer disease, each with at least 2 assessments across time. MAIN OUTCOME MEASURES: Scores on the cognitive Information-Memory-Concentration subscale of the Blessed Dementia Scale and the functional Weintraub Activities of Daily Living Scale. RESULTS: Low plasma levels of Abeta40, Abeta42, and high-sensitivity C-reactive protein were associated with a significantly more rapid cognitive decline, as indexed using the Blessed Dementia Scale, than were high levels. Low levels of Abeta42 and high-sensitivity C-reactive protein were significantly associated with more rapid functional decline on the Weintraub Activities of Daily Living Scale than were high levels. These plasma markers contributed about 5% to 12% of the variance accounted for on the Blessed Dementia Scale and the Activities of Daily Living Scale by fixed-effects predictors. Measures of folic acid metabolism were not associated with changes on either the Blessed Dementia Scale or the Activities of Daily Living Scale. CONCLUSIONS: Plasma markers of amyloid precursor protein metabolism and C-reactive protein may be associated with the rate of cognitive and functional decline in patients with Alzheimer disease.

Prevalence and effects of lobar microhemorrhages in early-stage dementia.

BACKGROUND: 80-100% of patients with Alzheimer's disease have vascular pathology related to cerebral amyloid angiopathy (CAA), and 5-7% have CAA-related lobar microhemorrhages (LMH) at autopsy. The prevalence and effects of LMH detectable by gradient echo MRI (GE-MRI) in early-stage dementia are unknown. OBJECTIVE: To obtain, using GE-MRI, a prevalence estimate for LMH in patients with early-stage dementia and to assess the effects of LMH on dementia severity. METHODS: Eighty-four subjects aged >or=55 years (range 58-89; mean 76) underwent cognitive and GE-MRI evaluation. The 84 subjects consisted of 61 consecutive subjects evaluated as part of an initial clinical evaluation for dementia and 23 consecutively evaluated healthy older subjects (controls). Data were analyzed for presence and number of LMH on GE-MRI and the effect of number of LMH on dementia severity. RESULTS: Nine (15%) of the 61 dementia patients versus 1 (4%) of the 23 control subjects demonstrated LMH on GE-MRI. Multiple (>or=2) LMH were found in 7 of the 9 (88%) dementia subjects with LMH (range of LMH counts 1-330) and no (0%) control subjects. Multivariable causal modeling indicated that number of LMH (p < 0.02), age (p < 0.01) and duration of symptoms (p < 0.001) significantly increased dementia severity while higher educational level (p < 0.001) was protective. CONCLUSIONS: LMH were detected by GE-MRI in 15% of patients with early-stage dementia and may contribute to dementia severity.