Predictors of Nursing Home Placement in a Cohort of European People with Alzheimer's Disease and Other Dementia Cases Enrolled in SCU-B or Non SCU-B Centers: The RECage Study.

Background: Nursing home placement (NHP) can be the final step of patients with Alzheimer's disease. Objective: We aimed to identify NHP predictors among 508 people with dementia with a 3-year follow-up. Methods: We analyzed data from the international observational RECage study, involving 508 people with especially Alzheimer's disease and comparing a cohort enrolled by five centers with a Special Care Unit for BPSD (behavioral and psychological symptoms of dementia) and another one enrolled by six centers lacking this facility. The tertiary objective of the study was to assess the possible role of the SCU-B in delaying NHP. We assessed the relationship of the baseline characteristics with NHP by means of univariate analysis followed by Cox's multivariate model. Results: Patients' mean age was 78.1 years, 54.9% were women. Diagnosis mean age was 75.4 (±8.32) years; the main diagnosis was Alzheimer's disease (296; 58.4%). During follow-up, 96 (18.9%) patients died and 153 (30.1%) were institutionalized without a statistically significant difference between the two cohorts (p = 0.9626). The mean NHP time was 902 (95% CI: 870-934). The multivariable analysis without death as a competing risk retained four independent predictors of NHP: age increase (hazard ratio (HR) = 1.023, 95% CI: 1.000-1.046), patient education level increase (HR = 1.062, 95% CI: 1.024-1.101), Neuropsychiatric Inventory total increase (HR = 1.018; 95% CI: 1.011-1.026), and total Mini-Mental State Examination as a favorable factor (HR = 0.948, 95% CI: 0.925-0.971). Gender (females versus males: HR = 1.265, 95% CI: 0.899-1.781) was included in the final Cox's model for adjusting the estimates for. Conclusions: Our data partially agree with the predictors of NHP in literature including the effect of high education level. No caregivers' factors were statistically significant. Clinical trial registration: NCT03507504.

Respectful Caring for the Agitated Elderly (ReCAGE): A Multicentre, Prospective, Observational Study to Evaluate the Effectiveness of Special Care Units for People with Dementia.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) bring complexity in the clinical management of people with dementia; therefore, it is important to evaluate different models of care, such as Special Care Units (SCU-B).∥Objective:To evaluate the SCU-B effectiveness toward alleviating BPSD and improving the quality of life (QoL) of patients and their caregivers.∥Methods:ReCAGE was a multicenter, controlled, longitudinal study where 508 patients with BPSD were enrolled in two cohorts: 262 patients from centers endowed with a SCU-B, and 246 from centers without SCU-B. Statistical analyses included factorial ANCOVA for comparison among centers. The primary endpoint was effectiveness of the SCU-B, measured through the Neuropsychiatric Inventory (NPI) changes. Secondary endpoints were change in QoL of patients and caregivers, and the tertiary endpoint was time to nursing home admission.∥Results:The NPI scores decreased in both arms, with a statistically significant difference from baseline to 36 months (p < 0.0001) in both cohorts. Over time, NPI decreased more steeply during the first year in the SCU-B arm, but in the following two years the slope was clearly in favor of the control arm. This different pattern of the two cohorts reached statistical significance at the interaction "cohort by time" (p < 0.0001). Conflicting results were found regarding the outcomes of quality of life, while there were no differences in time to institutionalization in both cohorts.∥Conclusion:The RECage study did not confirm the long-term superiority of the pathway comprising a SCU-B. A post-hoc analysis revealed data supporting their acute effectiveness during behavioral crises.

A Confirmatory and an Exploratory Factor Analysis of the Cohen-Mansfield Agitation Inventory (CMAI) in a European Case Series of Patients with Dementia: Results from the RECage Study.

BACKGROUND: One of the most widely used instruments for assessing agitation in dementia patients is the Cohen-Mansfield Agitation Inventory (CMAI), nevertheless no global score has been proposed. The aim of this study is: (a) to conduct a confirmatory (CFA) and exploratory factor analysis (EFA) of CMAI on people with dementia and Psychological and Behavioral Symptoms (BPSD), and (b) to propose an alternative structure, based on clinical criteria including all CMAI items. METHODS: Confirmatory and exploratory factor analyses were carried out on the CMAI 29 items administered at baseline to 505 patients with dementia (PwD) and BPSD enrolled in the international observational RECage study. RESULTS: The three-factor structure has not been confirmed by the CFA, whilst the EFA was carried out respectively on 25 items disregarding 4 items with a prevalence ≤5% and then on 20 items disregarding 9 items with a prevalence ≤10%. The four-factor structure explaining 56% of the variance comprised Physically Aggressive behavior, Verbally Aggressive behavior, Physically non-aggressive behavior, and Physically and verbally aggressive behavior. CONCLUSIONS: A new grouping of all items according to a clinical criterion is proposed, allowing for a more sensible evaluation of the symptoms leading to better differentiation.

BPSD Patterns in Patients With Severe Neuropsychiatric Disturbances: Insight From the RECAGE Study.

OBJECTIVE: Behavioral and psychological symptoms of dementia (BPSD) profiles vary depending on etiology in patients with mild-to-moderate BPSD. It is not known if similar differences exist in patients with severe BPSD. METHODS: We analyzed data collected at baseline in 398 patients with severe BPSD (NPI ≥ 32) and defined diagnosis of dementia (Alzheimer's disease [AD] 297; frontotemporal dementia [FTD] 39; Lewy body disease/Parkinsonian dementia [LBD/PD] 31; and vascular dementia [VD] 31) included in the European multicenter cohort RECAGE. RESULTS: Mean total NPI was 52.11 (18.55). LBD/PD patients demonstrated more hallucinations, more anxiety and more delusions than patients with other dementia. FTD patients had less delusions and more disinhibition than patients with other neurodegenerative disorders. These profiles overlapped partially with those reported in the literature in patients with less severe symptoms. CONCLUSION: Patients with severe BPSD display different and specific profiles of neuropsychiatric symptoms depending on dementia etiology.

The Italian Framework of Bipolar Disorders in the Elderly: Old and Current Issues and New Suggestions for the Geriatric Psycho-Oncology Research.

BACKGROUND: Older adults with mood disorders constitute a heterogeneous group in a complex spectrum interlinked with physical comorbidities. Worldwide, Bipolar disorders in older people (OABD) remain underestimated and underdiagnosed. OABD is challenging in the clinical setting and is associated with adverse outcomes (increased risk of anti-social behaviour triggered by inappropriate drugs and increased incidence of health deficits, including cancer). This article aims to describe the state of the art of OABD in the Italian framework and provide a new field of research. METHODS: We performed an overview of the literature, selecting our target population (over 65 years) and synthesising the main challenging issues. By exploiting the Italian database from the Minister of Health in 2021, we analysed epidemiological data in the age range 65-74 years and 75-84 years old. RESULTS: Females showed the highest prevalence and incidence in both groups, with a regional difference across the country but more evident in the Autonomous Provinces of Bolzano and Trento for the 65-74 years range. Several projects recently focused on this topic, and the urgency to define better the epidemiological framework is mandatory. CONCLUSIONS: This study represented the first attempt to report the comprehensive Italian framework on OABD aimed at fostering research activities and knowledge.

Italian guidance on Dementia Day Care Centres: A position paper.

Dementia Day Care Centres (DDCCs) are defined as services providing care and rehabilitation to people with dementia associated with behavioural and psychological symptoms (BPSD) in a semi-residential setting. According to available evidence, DDCCs may decrease BPSD, depressive symptoms and caregiver burden. The present position paper reports a consensus of Italian experts of different disciplines regarding DDCCs and includes recommendations about architectural features, requirements of personnel, psychosocial interventions, management of psychoactive drug treatment, prevention and care of geriatric syndromes, and support to family caregivers. DDCCs architectural features should follow specific criteria and address specific needs of people with dementia, supporting independence, safety, and comfort. Staffing should be adequate in size and competence and should be able to implement psychosocial interventions, especially focused on BPSD. Individualized care plan should include prevention and treatment of geriatric syndromes, a targeted vaccination plan for infectious diseases including COVID-19, and adjustment of psychotropic drug treatment, all in cooperation with the general practitioner. Informal caregivers should be involved in the focus of intervention, with the aim of reducing assistance burden and promoting the adaptation to the ever-changing relationship with the patient.

Implementation of the Community Occupational Therapy in Dementia program in Italy (COTiD-IT): qualitative survey to identify barriers and facilitators in implementation.

BACKGROUND: Community Occupational Therapy in Dementia in Italy (COTID-IT) is a feasible and effective treatment that aims improving the quality of life and well-being of people with dementia and caregivers. The implementation of the program in the national context has not been studied yet. AIM: The objective of this study is to identify barriers and facilitators in the Italian implementation of the program. METHODS: We designed a quantitative cross-sectional survey. A questionnaire was developed to collect descriptive data regarding the respondents, the perceived barriers and facilitators regarding the application of COTiD and possible actions to promote the implementation process. RESULTS: The questionnaire was sent to all 90 Italian OTs trained in the use of COTiD-IT from 2013 to 2020. 50 people responded (61%). Barriers to the implementation of the COTID-IT included lack of knowledge about Occupational Therapy and the COTID-IT program by other health professionals. In addition, the scarcity of economic funds invested in home rehabilitation is experienced as another significant barrier. Facilitators were found to be the presence of an interprofessional team interested in the COTID-IT program and occupational therapy and the fact that COTID-IT is supported by scientific evidence. The creation of national and regional inter professional education and support groups, the availability of online resources are seen as opportunities to better implement the COTID-IT program. CONCLUSIONS: Implementation of psychosocial interventions is complex. OTs in Italy should be increasingly included within health policies and care programs of people with dementia to promote the use of COTID-IT. Further studies are needed to detail the policy and methodological actions that OTs should take in the future to disseminate and consolidate this intervention.

MoCA 7.1: Multicenter Validation of the First Italian Version of Montreal Cognitive Assessment.

Background: The early detection of neurocognitive disorders, especially when mild, is a key issue of health care systems including the Italian Dementia National Plan. The Mini-Mental State Examination (MMSE), i.e., the reference screening tool for dementia in Italian Memory Clinics, has low sensitivity in detecting mild cognitive impairment (MCI) or mild dementia. Objective: Availability of a 10-minute screening test sensitive to MCI and mild dementia, such as the Montreal Cognitive Assessment (MoCA), is relevant in the field. This study presents initial validity and reliability data for the Italian version of MoCA 7.1 that is being collected as part of a large ongoing longitudinal study to evaluate the rate of incident MCI and dementia in older adults. Methods: MoCA 7.1 and MMSE were administered to cognitive impaired patients (n = 469; 214 with MCI, 255 with dementia; mean age: 75.5; 52% females,) and healthy older adults (n = 123, mean age: 69.7, 64 % females). Results: Test-retest (0.945, p < 0.001) and inter-rater (0.999, p < 0.001) reliability of MoCA 7.1, assessed on randomly selected participants with normal cognition, MCI, dementia, were significant. MoCA 7.1 showed adequate sensitivity (95.3%) and specificity (84.5%) in detecting MCI compared to MMSE (sensitivity: 53.8%; specificity: 87.5%). The Area Under the Curve of MoCA 7.1 was significantly greater than that of MMSE (0.963 versus 0.742). MoCA 7.1 showed similar results in detecting both MCI and dementia. Conclusion: MoCA 7.1 is a reliable and useful tool that can aid in the diagnosis of MCI and dementia in the Italian population.

Combined Effects of Age and Comorbidities on Electrocardiographic Parameters in a Large Non-Selected Population.

Background: Previous studies have evaluated average electrocardiographic (ECG) values in healthy subjects or specific subpopulations. However, none have evaluated ECG average values in not selected populations, so we examined ECG changes with respect to age and sex in a large primary population. Methods: From digitized ECG stored from 2008 to 2021 in the Modena province, 130,471 patients were enrolled. Heart rate, P, QRS and T wave axis, P, QRS and T wave duration, PR interval, QTc, and frontal QRS-T angle were evaluated. Results: All ECG parameters showed a dependence on age, but only some of them with a straight-line correlation: QRS axis (p < 0.001, R2 = 0.991, r = 0.996), PR interval (p < 0.001, R2 = 0.978, r = 0.989), QTc (p < 0.001, R2 = 0.935, r = 0.967), and, in over 51.5 years old, QRS-T angle (p < 0.001, R2 = 0.979, r = 0.956). Differences between females and males and in different clinical settings were observed. Conclusions: ECG changes with ageing are explainable by intrinsic modifications of the heart and thorax and with the appearance of cardiovascular diseases and comorbidities. Age-related reference values were computed and applicable in clinical practice. Significant deviations from mean values and from Z-scores should be investigated.

Rationale, Design, and Methodology of a Prospective Cohort Study for Coping with Behavioral and Psychological Symptoms of Dementia: The RECage Project.

BACKGROUND: Behavioral and psychological symptoms of dementia (BPSD) are quite challenging problems during the dementia course. Special Care Units for people with dementia (PwD) and BPSD (SCU-B) are residential medical structures, where BPSD patients are temporarily admitted, in case of unmanageable behavioral disturbances at home. OBJECTIVE: RECage (REspectful Caring for AGitated Elderly) aspires to assess the short and long-term effectiveness of SCU-Bs toward alleviating BPSD and improving the quality of life (QoL) of PwD and their caregivers. METHODS: RECage is a three-year, prospective study enrolling 500 PwD. Particularly, 250 community-dwelling PwDs presenting with severe BPSD will be recruited by five clinical centers across Europe, endowed with a SCU-B, for a short period of time; a second similar group of 250 PwD will be followed by six other no-SCU-B centers solely via outpatient visits. RECage's endpoints include short and long-term SCU-B clinical efficacy, QoL of patients and caregivers, cost-effectiveness of the SCU-B, psychotropic drug consumption, caregivers' attitude toward dementia, and time to nursing home placement. RESULTS: PwD admitted in SCU-Bs are expected to have diminished rates of BPSD and better QoL and their caregivers are also expected to have better QoL and improved attitude towards dementia, compared to those followed in no-SCU-Bs. Also, the cost of care and the psychotropic drug consumption are expected to be lower. Finally, PwD followed in no-SCU-Bs are expected to have earlier admission to nursing homes. CONCLUSION: The cohort study results will refine the SCU-B model, issuing recommendations for implementation of SCU-Bs in the countries where they are scarce or non-existent.

The CITIMERIVA Study: CITIcoline plus MEmantina plus RIVAstigmine in Older Patients Affected with Alzheimer's Disease.

OBJECTIVE: Combined therapy of memantine or acetylcholinesterase inhibitors, with cholinergic precursors such as citicoline, can be effective in Alzheimer's disease. Indeed, they are able to increase the intrasynaptic levels of acetylcholine more than the single drug. Our aim was to evaluate the efficacy and safety of oral citicoline plus memantine plus rivastigmine in patients with Alzheimer's disease. METHODS: This was a multi-centric, retrospective case-control study conducted in Italian Centers for Cognitive Impairment and Dementia on consecutive patients aged 65 years or older affected with Alzheimer's disease. Overall, 104 patients were recruited (27% male, mean age 76.04 ± 4.92 years); 41 (39.42%) treated with citicolin 1000 mg/day given orally + memantine + rivastigmine (Cases) and 63 (60.58%) treated with memantine + rivastigmine (Controls). At baseline (T0), month 6 (T1) and month 12 (T2), cognitive functions were assessed by the Mini Mental State Examination (MMSE), functional dependence by basal Activities (ADL) and Instrumental Activities of Daily Living (IADL), comorbidity by the Cumulative Illness Rating Scale (CIRS), mood by the Geriatric Depression Scale (GDS), and behavioural disturbances by the Neuropsychiatric Inventory (NPI). Adverse events were reported during the study. RESULTS: The difference in MMSE score was not significant when comparing the two groups at T0, T1 or T2. However, in the case group, the MMSE total score showed a statistically significant difference at T0 versus T1 (13.63 ± 2.46 vs. 14.17 ± 2.24; p = 0.008), and at T0 versus T2 (13.63 ± 2.46 vs. 14.32 ± 2.53; p = 0.002). In the control group, no statistical differences were found at baseline (T0), T1 and T2. ADL, IADL, GDS and NPI total score did not improve during the study in either the case or the control group. CONCLUSIONS: In our study we observed absence of a statistically significant difference between case and control groups for the MMSE total scores. However, in the case group in the MMSE total scores, there was a statistically significant increase between the baseline and the end of the study.

A Retrospective Study on the Benefits of Combined Citicoline, Memantine, and Acetylcholinesterase Inhibitor Treatments in Older Patients Affected with Alzheimer's Disease.

BACKGROUND: Background: Citicoline has been proven to have beneficial effects in patients with cognitive impairment. In previous studies, combined treatment with memantine and acetylcholinesterase inhibitors (AChEIs) maintained cognitive function in patients with Alzheimer's disease (AD) better than memantine or AChEIs alone. OBJECTIVE: To evaluate the effectiveness and safety of a combination therapy of oral citicoline, memantine, and an AChEI in AD when compared with memantine and an AChEI without citicoline. METHODS: This was a retrospective multi-centric case-control study, conducted in Italian Centers for Cognitive Impairment and Dementia. Overall, 170 patients were recruited (34.11%of men, mean age 76,81±4.93 years): 48.8%treated with memantine and donepezil; 48.2%with memantine and rivastigmine; 2.9%with memantine and galantamine. 89 patients (control-group) were treated with memantine and an AChEI, whereas 81 patients (case-group) were treated with oral citicoline 1000 mg/day added to memantine and an AChEI given orally. Cognitive functions, activities of daily living, instrumental activities of daily living, comorbidities, mood and behavioral disturbances were assessed at baseline, month 6, and month 12. RESULTS: In the case group, MMSE score had a statistically significant increasing trend between T0 and T2 (14.88±2.95 versus 15.09±3.00; p = 0.040), whereas in the control group, MMSE score showed a statistically significant decrease trend (14.37±2.63 versus 14.03±2.92 p = 0.024). CONCLUSION: In older patients with AD, a triple therapy with citicoline, memantine, and AChEI was more effective than memantine and AChEI without citicoline in maintaining the MMSE total score after 12 months.

Prevalence and management of delirium in community dwelling older people with dementia referred to a memory clinic.

OBJECTIVE: Our aim was to measure the prevalence of delirium, its clinical features, and outcomes in older patients referred to a memory clinic. METHODS: A retrospective cohort study of 109 older outpatients with delirium referred to a memory clinic with a home care service. Delirium was diagnosed using the confusion assessment method and dementia with the DSM-5 criteria. We collected information on cognitive and functional status, mortality, institutionalization, and hospitalization during 6 months following the delirium episode. RESULTS: Delirium prevalence was 3.6%, mostly of hyperactive type. Delirium worsened functional (ADL 2.95 ± 1.95 vs. 2.16 ± 1.84) and cognitive (MMSE 13.88 ± 8.96 vs.11.0 ± 9.49) status after 6 months compared to the baseline. The mortality rate was 29.4%, and 28.3% were admitted to a long-term facility after the episode of delirium. Of these patients, more than half were hospitalized during the follow-up. Of the 109 patients with delirium, 85 were managed at home and 24 were hospitalized. Patients who were hospitalized had more severe behavioral symptoms during the delirium episode. There was no difference in mortality and institutionalization according to the home or hospital management. CONCLUSIONS: This retrospective cohort study adds novel information to the existing literature of an understudied setting and population. The study supports the need to further investigate the feasibility and efficacy of the hospital at home models for the prevention and management of delirium in a high-risk population.

Activity-based occupational therapy intervention for delirium superimposed on dementia in nursing home setting: a feasibility study.

OBJECTIVE: Multi-component interventions can reduce delirium incidence. Occupational therapy (OT) has been effective in the management of dementia. We designed a real-world feasibility study of an OT intervention in the management of delirium superimposed on dementia (DSD). METHODS: We included a convenient sample of 22 patients older than 65 years of age with delirium and moderate dementia admitted to a nursing home (NH). The OT procedures were standardized according to the level of agitation or sedation of the patient and based on a structured OT evaluation. The Canadian Occupational Performance Measure (COPM) was used to evaluate the proxy perception of performance in the daily activities at baseline and at delirium resolution. RESULTS: The mean age was 86.45 ± 6.46 years. The first daily treatment was delivered in the entire sample, while the second was delivered in 63.46% on day 1, 72.72% on day 2, 25% on day 3, 66.67% on day 4, 100% on days 5 and 6. The main time of the first daily treatment varied, day 1 through day 6, from 14.8 ± 8.5 to 20 ± 0 min; while the second daily treatment, in the same period, from 3.9 ± 6.7 to 20.1 ± 0 min. The mean time of the first treatment varied day 1 through day 6 from 14.8 ± 8.5 to 20 ± 0 min, while the second treatment from 3.9 ± 6.7 to 20.1 ± 0 min. The COPM proxy performance and proxy satisfaction increased from delirium onset to delirium resolution. CONCLUSIONS: This is the first study to report the feasibility of an OT intervention for the management of DSD in a NH setting. The results are important to support future trials on delirium management in a setting often understudied and underrepresented.

A pilot study of community-based occupational therapy for persons with dementia (COTID-IT Program) and their caregivers: evidence for applicability in Italy.

OBJECTIVE: To assess the applicability in Italy of a community-based occupational therapy program (COTID) on occupational performance of persons with dementia and their caregivers. METHODS: Prospective cohort study: twenty-seven older persons with mild-to-moderate dementia living in the community and their primary caregivers were included. Ten sessions of occupational therapy over 5 weeks were delivered. Main outcome measures were the level of performance and satisfaction perceived by people with dementia during the participation in significant activities assessed with the Canadian Occupational Performance Measure (COPM); caregiver burden assessed with the sense of competence questionnaire (SCQ). RESULTS: The average age of the population was 80.59 ± 8.46 in persons with dementia and 57.78 ± 13.47 in the caregivers. There was a significant improvement in the caregivers' burden in the SCQ (pre treatment 77.19 ± 13.27 vs 82.56 ± 12.57 post treatment; p = .005). Persons with dementia showed a significant improvement in the COPM performance (4.56 ± 1.44 vs 6.68 ± 1.59; p = .000) as well as in the satisfaction (5.08 ± 1.84 vs 7.04 ± 1.71; p = .000). No significant variations were registered in the overall cognitive functions, behavioral and psychological symptoms of dementia, daily functioning, depressive symptoms, perceived quality of life and global health of people with dementia. There was also no difference in the quality of life, global health, depression or burden in the caregivers. CONCLUSIONS: The study shows that the COTID program is applicable in the Italian context. The findings suggest a positive effect on patients and caregivers providing a preliminary support for the program implementation at a national level.