What Could Be the Main Levers to Promote a Timely Diagnosis of Neurocognitive Disorders?

BACKGROUND: Neurocognitive disorders (NCD) are a growing health issue and the importance of diagnosis is still debated despite the benefits of making a diagnosis appearing to be greater than the risks. OBJECTIVE: The aim of the present study was to explore the perception of the main benefits and risks to perform a diagnosis workup of NCD in a population of general practitioners (GPs), specialized physicians (SPs), other healthcare professionals (OHPs), and informal caregivers (ICs), and to identify the lowest perceived benefits and the highest perceived risks that could be levers to promote a diagnosis of NCD. METHODS: A standardized questionnaire was submitted to GPs, SPs, OHPs, and ICs aiming to evaluate the importance of eight benefits and eight risks related to NCD diagnosis (selected from the literature) for four prototypical clinical cases at different stages of the disease: subjective cognitive impairment/mild NCD, major NCD at mild/moderate stage, moderate stage with behavioral and psychotic symptoms, and severe stage. RESULTS: The lowest perceived benefits of making an NCD diagnosis were "access to medical research", "patient's right to know", and "initiation of symptomatic drug treatment". The highest perceived risks of making an NCD diagnosis were "negative psychological impact for the patient", "absence of disease-modifying treatment", and "absence of suitable institution". CONCLUSION: This study highlights the lowest perceived benefits and the highest perceived risks of making an NCD diagnosis. These benefits and risks could be modified to become levers to promote a personalized diagnosis of NCD.

Immediate Benefit of Art on Pain and Well-Being in Community-Dwelling Patients with Mild Alzheimer's.

OBJECTIVE: The present report aims to evaluate whether singing intervention can bring an immediate benefit that is greater than the one provided by painting intervention on pain and well-being. METHODS: Fifty-nine mild patients with Alzheimer disease were randomized to a 12-week singing (n = 31) or painting group (n = 28). In the present analysis, the immediate evolution of pain and well-being was compared across sessions between the 2 groups using mixed-effects models. RESULTS: We observed a significant improvement in well-being for both singing and painting groups immediately after sessions, compared to the assessment before the sessions. We did not observe this improvement across the sessions for pain intensity measurement. DISCUSSION: Our results revealed that both painting and singing interventions provide an immediate benefit on the patients' well-being.

Perception of Benefits and Risks of Neurocognitive Disorders Diagnosis: A French National Survey.

BACKGROUND: Neurocognitive disorders (NCD) are underdiagnosed in primary care, mainly because of the misunderstanding of benefits associated with timely diagnosis. OBJECTIVE: The aim of this study was to explore the benefits and risks of diagnosis in a population of general practitioners (GPs), specialized physicians (SPs), other healthcare professionals (HPs), and informal caregivers (ICs). METHODS: A questionnaire was submitted to GPs, SPs, HPs. and ICs. It aimed at evaluating benefits and risks related to NCD diagnosis associated with four prototypical clinical cases at different stages: isolated cognitive complaint/mild NCD, major NCD at mild/moderate stage, moderate stage with behavioral and psychotic symptoms, and severe stage. The concepts of early, timely, and personalized diagnosis were evaluated. RESULTS: A total of 719 completed surveys were collected from 183 GPs, 176 SPs, 281 HPs, and 79 ICs. More than 90% of the participants considered initiating a diagnosis as relevant except at the severe stage. Benefits were superior to risks for all groups and all four cases alike (p < 0.001). Benefits were lower according to GPs and higher for SPs than the other groups at the first two stages (p < 0.001). At the moderate stage, there were few differences between groups. At the severe stage, GPs and SPs claimed it was less relevant to carry out a diagnosis than the other groups (p < 0.001). Risks were higher for ICs and lower for SPs (p < 0.001). The best diagnosis concept was the personalized diagnosis. CONCLUSION: Benefits appeared more relevant than risks with differences according to the stage of the disease and type of respondents.

Personality Modulates the Efficacy of Art Intervention on Chronic Pain in a Population of Patients with Alzheimer's Disease.

BACKGROUND: Alzheimer's disease (AD) mainly occurs in elderly individuals. Comorbidities and chronic pain are frequent in this population. Previous studies revealed that personality modulates both chronic pain (CP) andADoccurrence and evolution. Moreover, as pain treatments can induce side-effects, non-drugs treatments, such as art interventions, are interesting alternative therapies for decreasing CP in these patients. OBJECTIVE: Our aim was to assess the potential role of personality traits on art intervention efficacy for reducing CP in a population of patients with mild AD. METHODS: Design: multicenter randomized controlled trial. Fifty mild AD patients underwent a 12-week art intervention including singing and painting groups. Personality was assessed with the Big Five Inventory before the sessions. CP was measured with Numeric Rating Scale (NRS) [Usual pain (NRS-U) and most Intense pain (NRS-I)], Simple Visual Scale [Usual pain (SVS-U) and most Intense pain (SVS-I)] and Brief Pain Inventory (BPI) before and after the sessions. The influence of personality traits on CP evolution before and after art intervention was assessed with multiple linear regression models. RESULTS: A positive association was observed between neuroticism and the evolution of three CP measures including NRS-U (B = 0.34, p = 0.01), SVS-U (B = 0.20, p = 0.04), and BPI-U (B = 0.46, p = 0.02) evolution. No significant relationship was observed between neuroticism and NRS-I, SVS-I and BPI-R evolution. CONCLUSIONS: Our findings suggest that neuroticism can decrease the efficacy of group art intervention on pain in patients with mild AD. Individual therapies could be more appropriate for these patients. These results emphasize the interest of taking into account patients' personality before proposing them to participate to a group therapy.

Predictors of Discharge Destinations and Three-Month Evolution of Patients Initially Hospitalized in a Cognitive Behavioral Unit.

BACKGROUND: Previous studies showed that a third of patients living at home entered an institution after hospitalization in Cognitive and Behavioral Units (CBUs). OBJECTIVE: The main objective of this study was to identify predictors of discharge destination for these patients. The secondary objective was to estimate whether institutionalization can have an impact on a patient's long-term prognosis. METHODS: The study population was selected from the EVITAL study and included 140 participants living at home before hospitalization in CBUs. Factors favoring nursing-home admission were investigated and the impact of discharge destinations (i.e., home or nursing home) on patients' prognosis was examined. RESULTS: Institutionalized patients were more likely to be women (F = 4.7; p = 0.03), with a higher dementia severity (F = 9.82; p = 0.007), often living alone (F = 19.69; p = 0.001), with a caregiver other than spouse (F = 8.93; p = 0.003), and with a higher patient quality of life (QoL) according to the caregiver (F = 11.73; p = 0.001). When using multivariate logistic linear regressions, we showed a relationship between marital status (OR = 0.19, 95% CI: 0.08-0.43, p < 0.001), dementia severity (OR = 0.15, 95% CI: 0.03-0.79, p = 0.03), QoL (OR = 0.88, 95% CI: 0.79-0.98, p = 0.017), and institutionalization. At three months, a higher overall rate of rehospitalization (F = 12.21; p < 0.001) and rehospitalization for behavioral and psychological symptoms of dementia (F = 6.76; p = 0.006) were observed for patients staying at home after CBU discharge. CONCLUSION: Our study allows for a better understanding of the institutionalization risk factors of the patients hospitalized in CBUs. Identification of these factors could help clinicians to better support patients and to help the transition to be smoother. Moreover, our results suggest that prognosis of institutionalized patients is not unfavorable when compared with patients staying at home.

Can Musical or Painting Interventions Improve Chronic Pain, Mood, Quality of Life, and Cognition in Patients with Mild Alzheimer's Disease? Evidence from a Randomized Controlled Trial.

BACKGROUND: Among non-pharmacological therapies, musical intervention is often used for patients with Alzheimer's disease (AD) and patients presenting chronic pain. However, their efficacy is still under debate. OBJECTIVE: Our aim was to determine the efficacy of choral singing versus painting sessions on chronic pain, mood, quality of life, and cognition in AD patients. METHODS: In this multicenter randomized controlled trial, 59 mild AD patients were randomized to a 12-week singing (SG; n = 31) or painting group (PG; n = 28). Chronic pain, anxiety, depression, and quality of life were assessed before, after, and 1 month after the sessions. Cognitive abilities were assessed before and after interventions. The evolution of these different measures was assessed with mixed linear models. The primary data analysis was by intention-to-treat, and completed by a 'per protocol' approach. RESULTS: Both singing and painting interventions led to significant pain reduction (Time effect: F = 4.71; p = 0.01), reduced anxiety (Time effect: F = 10.74; p < 0.0001), improved Quality of Life (Time effect: F = 6.79; p = 0.002), improved digit span (F = 12.93; p = 0.001), and inhibitory processes (Time effect: F = 4.93; p = 0.03). Depression was reduced over time in PG only (Time x Group effect: F = 4.53; p = 0.01). Verbal Memory performance remained stable over time in SG, but decreased in PG (Time x group effect: F = 9.29; p = 0.004). CONCLUSION: Findings suggest that singing and painting interventions may reduce pain and improve mood, quality of life, and cognition in patients with mild AD, with differential effects of painting for depression and singing for memory performance.

Cognitive and imaging markers in non-demented subjects attending a memory clinic: study design and baseline findings of the MEMENTO cohort.

BACKGROUND: The natural history and disease mechanisms of Alzheimer's disease and related disorders (ADRD) are still poorly understood. Very few resources are available to scrutinise patients as early as needed and to use integrative approaches combining standardised, repeated clinical investigations and cutting-edge biomarker measurements. METHODS: In the nationwide French MEMENTO cohort study, participants were recruited in memory clinics and screened for either isolated subjective cognitive complaints (SCCs) or mild cognitive impairment (MCI; defined as test performance 1.5 SD below age, sex and education-level norms) while not demented (Clinical Dementia Rating [CDR] <1). Baseline data collection included neurological and physical examinations as well as extensive neuropsychological testing. To be included in the MEMENTO cohort, participants had to agree to undergo both brain magnetic resonance imaging (MRI) and blood sampling. Cerebral 18F-fluorodeoxyglucose positon emission tomography and lumbar puncture were optional. Automated analyses of cerebral MRI included assessments of volumes of whole-brain, hippocampal and white matter lesions. RESULTS: The 2323 participants, recruited from April 2011 to June 2014, were aged 71 years, on average (SD 8.7), and 62% were women. CDR was 0 in 40% of participants, and 30% carried at least one apolipoprotein E ε4 allele. We observed that more than half (52%) of participants had amnestic mild cognitive impairment (17% single-domain aMCI), 32% had non-amnestic mild cognitive impairment (16.9% single-domain naMCI) and 16% had isolated SCCs. Multivariable analyses of neuroimaging markers associations with cognitive categories showed that participants with aMCI had worse levels of imaging biomarkers than the others, whereas participants with naMCI had markers at intermediate levels between SCC and aMCI. The burden of white matter lesions tended to be larger in participants with aMCI. Independently of CDR, all neuroimaging and neuropsychological markers worsened with age, whereas differences were not consistent according to sex. CONCLUSIONS: MEMENTO is a large cohort with extensive clinical, neuropsychological and neuroimaging data and represents a platform for studying the natural history of ADRD in a large group of participants with different subtypes of MCI (amnestic or not amnestic) or isolated SCCs. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01926249 . Registered on 16 August 2013.

One-Year Evolution of Behavioral and Psychological Symptoms of Dementia in Patients Initially Hospitalized in Cognitive Behavioral Units: The EVITAL Prospective Cohort.

BACKGROUND: The 2008-2012 French Alzheimer's Plan has provided hospital Cognitive and Behavioral Units (CBU) to improve the management of patients with productive behavioral and psychological symptoms of dementia (BPSD). Little is known concerning the behavioral outcome of these patients after discharge. OBJECTIVE: The present study investigated the long-term evolution of BPSD over one year after CBU discharge. METHODS: The EVITAL cohort included 221 participants admitted to the CBUs of 3 French hospitals. BPSD were collected using the Neuropsychiatric Inventory (NPI) at admission and 3, 6, and 12 months after hospitalization. The global NPI score evolution was assessed using a linear mixed-effect model. A four-factor model of the NPI including behavioral dyscontrol, psychosis, mood, and agitation subscores was also analyzed. RESULTS: Our analysis focused on 148 patients followed up during 12 months and evaluated at each visit. The global NPI score was 48.5 (SD 21.7) at baseline, 28.8 (SD 18.7) at 3-month, 23.2 (SD 16.4) at 6-month and 20.9 (SD 15.9) at 12-month follow-up. The score significantly decreased from baseline to follow-up (F = 109.3 p < 0.0001). Moreover, the decrease was observed for each NPI subscores. The Clinical Dementia Rating (CDR) scale score was significantly linked to the baseline NPI score (t = 2.76, p = 0.009). Conversely, the NPI decline was observed whatever the CDR level. CONCLUSION: The present study showed a decrease in the global NPI score and all its subscores during the year following the CBU hospitalization, regardless of the initial CDR score.

[Impact of occupational therapy on the experience of carers]. / Impact d'une prise en charge ergothérapeutique sur le ressenti des aidants.

A study was carried out in 2014 and 2015 analysing the effects of occupational therapy on the carers of patients with Alzheimer's disease or related conditions. The level of "burden" felt by carers was measured before and after this therapy. The results show a real improvement in the quality of their daily life.

[Role of personality, familial environment, and severity of the disease on the behavioral and psychological symptoms of dementia]. / Particularités sémiologiques des symptômes comportementaux et psychologiques de la démence en fonction de la personnalité antérieure, de l'environnement familial et de la sévérité de la démence.

The phenomenology of Behavioral and Psychological Symptoms of Dementia (BPSD) occurring in the Alzheimer's disease and related syndromes remains not well known. The goal of this study was to assess the role of disorders of personality, psychiatric disorders and home environment in the occurence of the BPSD; 99 inpatients from a short-term Alzheimer unit were included in the study. BPSD were assessed by the NeuroPsychiatric Inventory, the severity of dementia by the MMSE. Previous somatic, psychiatric and personality disorders were evaluated by a semi-structured interview of the family, and classified according to the A, B and C groups from the DSM-IV. Eighty eight percent of the patients presented at least one BPSD. The patients whose the main caregiver was a spouse appeared to be more aggressive. Sixty seven per cent of the patients presented with former disorders of personality; they were more delirious, more anxious, more irritable and suffered more disorders of appetite. Each type of personality disorder modified the phenomenology of the BPSD. The severity of dementia does not seem sufficient to explain the occurrence of BPSD. Other factors seem to play a dominating part such as the previous disorders of personality and psychiatric antecedents. However, the exact links between disorders of personality, psychiatric antecedents and BPSD remain difficult to specify.