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.

Undertreatment of patients with Alzheimer's disease in an elderly United States population.

BACKGROUND: The aim of this study was to assess the undertreatment of elderly mild to moderate Alzheimer's disease (AD) patients in the United States utilizing baseline data from a community-based trial that has established comparability to national survey samples on demographic characteristics. METHODS: Baseline data were used from an open-label, 12-week, postapproval study of compliance with galantamine, an AChEI and nicotinic receptor modulator, and vitamin E. A total of 2,114 patients from 406 community-based US practices in which physicians had previously treated patients with acetylcholinesterase inhibitors (AChEIs) were included in the study. This population reflects a large, ethnically diverse patient pool consistent with the demographics of the elderly population in the United States, atypical of those enrolled in most AD trials. RESULTS: The majority of patients (64.5%) were described by either themselves or their caregivers as not having received prior AChEI treatment. Positive associations were found between past AChEI treatment and longer time since diagnosis, white race, higher education, medical care by a neurologist, and older caregivers. The likelihood of having received previous AChEI treatment was higher among white patients (61.9%) than among those from other ethnic groups combined (25.8%). CONCLUSIONS: The similarity of patient demographic characteristics to the 2000 US Census figures for the population aged >65 years makes this data set a potentially powerful tool for planning public health initiatives. Findings suggest that patients with mild to moderate AD are undertreated and that specialist and nonspecialist organizations should discuss and implement ways to optimize management of this disease.

Effects of rivastigmine on behavioral and psychological symptoms of dementia in Alzheimer's disease.

BACKGROUND: The presence of certain behavioral and psychological symptoms (eg, paranoia, hallucinations, aggression, activity disturbances) in Alzheimer's disease (AD) may predict faster cognitive and functional decline; therefore, such symptoms represent an important treatment target. Behavioral and psychological symptoms of dementia (BPSD) may be caused at least in part by cholinergic deficits. Regulatory studies of rivastigmine in AD were not designed to evaluate effects on BPSD, but further investigation of rivastigmine in AD was prompted by later studies demonstrating behavioral benefits in other types of dementia. OBJECTIVE: The primary aim of this article was to review available data on the behavioral benefits of rivastigmine in patients with AD. METHODS: Relevant data were identified through a MEDLINE search for studies published in peer-reviewed journals through January 2004. The search terms were Alzheimer, behavior, psychosis, and rivastigmine. Data presented at international scientific congresses were also reviewed to ensure that the most recent data were considered. RESULTS: A meta-analysis of three 6-month, placebo-controlled trials of rivastigmine in mild to moderate AD indicated that rivastigmine 6 to 12 mg/d may improve or prevent disruptive BPSD (P < 0.05 vs placebo). In patients with more advanced AD, 2 open-label studies of up to 12 months' duration found that improvements in BPSD were accompanied by a decrease in the use of psychotropic medications. Rivastigmine demonstrated behavioral benefits in patients with dementia with Lewy bodies (DLB) in a double-blind, placebo-controlled study (P < 0.05). In open-label extension studies, rivastigmine provided sustained effects (up to 2 years) in patients with mild to moderate AD or DLB. CONCLUSIONS: The available dats suggest that rivastigmine may be a well-tolerated treatment option for improving or preventing psychotic and nonpsychotic symptoms associated with AD. Prospective, double-blind studies are needed to evaluate these preliminary findings.

A randomized, placebo-controlled study of the efficacy and safety of sertraline in the treatment of the behavioral manifestations of Alzheimer's disease in outpatients treated with donepezil.

OBJECTIVE: To examine the safety and efficacy of sertraline augmentation therapy in the treatment of behavioral manifestations of Alzheimer's disease (AD) in outpatients treated with donepezil. METHODS AND MATERIALS: Patients with probable or possible AD, and a Neuropsychiatric Inventory (NPI) total score >5 (with a severity score > or =2 in at least one domain), were treated with donepezil (5-10 mg) for 8 weeks, then randomly assigned to 12 weeks of double-blind augmentation therapy with either sertraline (50-200 mg) or placebo. Primary efficacy measures were the 12-item Neuropsychiatric Inventory (NPI) and the Clinical Global Impression Improvement (CGI-I) and Severity (CGI-S) scales. RESULTS: 24 patients were treated with donepezil+sertraline and 120 patients with donepezil+placebo. There were no statistically significant differences at endpoint on any of the three primary efficacy measures. However, a linear mixed model analysis found modest but statistically significantly greater improvements in the CGI-I score on donepezil+sertraline. Moreover, in a sub-group of patients with moderate-to-severe behavioral and psychological symptoms of dementia, 60% of patients on sertraline vs 40% on placebo (p = 0.006) achieved a response (defined as > or = 50% reduction in a four-item NPI-behavioral subscale). One adverse event (diarrhea) was significantly (p < 0.05) more common in the donepezil+sertraline group compared to the donepezil+placebo group. CONCLUSION: Sertraline augmentation was well-tolerated in this sample of AD outpatients. In addition, post hoc analyses demonstrated a modest but statistically significant advantage of sertraline over placebo augmentation in mixed model analyses and a clinically and statistically significant advantage in a subgroup of patients with moderate-to-severe behavioral and psychological symptoms of dementia.

Morning or evening activity improves neuropsychological performance and subjective sleep quality in older adults.

STUDY OBJECTIVES: Sleep disturbances and decline in neuropsychological performance are common in older adults. Reduced social and physical activity is likely a contributing factor for these age-related changes in sleep and cognition. We previously demonstrated that a program of structured social and physical activity, with 2 daily activity sessions, 1 in the morning and 1 in the evening for a relatively short period of 2 weeks, improved sleep and neuropsychological performance in community-dwelling older adults. The goals of this pilot study were to determine whether a single daily morning or evening activity session for 2 weeks would also improve sleep and neuropsychological function and whether these effects were dependent on the timing of the activity sessions. DESIGN: We compared the effect of morning or evening structured activity sessions in a repeated-measures crossover design. Subjective mood, neuropsychological performance tasks, and subjective and objective measures of sleep were assessed at baseline and after the intervention. SETTING: All procedures took place in the participant's residence. PARTICIPANTS: Twelve older men and women (74.6 +/- 5.5 years of age). INTERVENTIONS: Subjects participated in 14 days of structured activity sessions in the morning (9:00-10:30 am) or evening (7:00-8:30 pm). Sessions consisted of stretching, low-impact aerobics, and game playing. MEASUREMENTS AND RESULTS: Exposure to either morning or evening activity significantly improved performance on a neuropsychological test battery. Morning activity sessions increased throughput on 4 of 8 performance tasks, while evening activity sessions improved throughput on 7 of the 8 performance tasks. Subjective sleep-quality ratings, measured by the Pittsburg Sleep Quality Index, improved following activity sessions in either the morning or the evening. Objective measures of sleep did not improve when measured by actigraphy or polysomnography. CONCLUSIONS: These results suggest that short-term exposure to either morning or evening social and physical activity improves objective measures of neuropsychological performance and subjective sleep quality in the elderly. Increasing exposure to social and physical activity may be a useful intervention to improve sleep quality and daytime function in older adults.

Dementia patients in primary care. Care managers offer a solution to providing ongoing care.

The structure of our healthcare system does not take into consideration the many psychological and social needs of older patients. For a patient like Mr. G, who has mild-to-moderate dementia, a critical aspect of primary medical care is determining the patient's non-medical needs. These needs often bear directly on medical care. Cost is one reason primary care offices do not have more care managers. Yet, in the seven intervention sites participating in the Council for Jewish Elderly study, six have arranged to continue with the social worker or have made substantial efforts to come up with the funding to do so. As we continue to look at our changing demographics and the needs of our increasingly older population, public policy planners must look at care management in primary care settings as an important clinical provision of care. To find a care manager in your area, log on to www.caremanager.org, which is the web site of the National Association of Professional Geriatric Care Managers. Click on the "Find a Care Manager" link and fill out the search form.

Cognitive screening in the primary care setting. The role of physicians at the first point of entry.

There are many reasons why it is important to conduct the cognitive assessment and arrive at a preliminary diagnosis within the primary care setting. In addition to starting the patient on anti-cholinesterase medications, the physician must discuss with the family (and often the patient) issues related to financial matters and self-care. Alzheimer's patients who live alone may be targets for financial and personal exploitation, and are at risk for self-neglect. Community support or provision might be needed to assist with medication compliance, provide nutritional services by shopping for prepared foods or through Meals on Wheels, housekeeping to maintain cleanliness, adult day services to provide social and recreational activities, live-in companions, and assistance with other instrumental activities of daily living. Sometimes more structured or institutional living is necessary. Generally, the primary care practice is not set up to coordinate these additional services, as well as to provide ongoing care. We will discuss potential solutions to providing ongoing care in next month's column.

Behavioral and psychologic symptoms of dementia.

Although tremendous strides with regard to identification and treatment of BPSD have been made over the last several decades, much work remains. Presently, BPSD research opportunities are at their greatest. The increasing worldwide social and economic impact of BPSD, however, requires that researchers, clinicians, and scientists develop a global network focused on collaboration and innovation. In particular, research must address cross-culturally applicable methods for assessment, exploration of the environmental relationships of BPSD and the underlying biologic and psychologic substrates, longitudinal evaluation, determination of the frequency and underlying pathogenic mechanisms, and development of a clearly defined treatment method profile with specific reference to different types of BPSD [134].

Behavioral and psychological symptoms of dementia. Assisting the caregiver and managing the patient.

Behavioral and psychological symptoms of dementia cause many problems for patients and caregivers. Fortunately, physician intervention and pharmacologic and nonpharmacologic approaches to managing the patient provide hope for successful treatment. New antipsychotic agents and pharmacologic treatments are in development and may provide greater benefits to patients and their caregivers.

A Retrospective Chart Review of Antidepressant Use, Effectiveness, and Adverse Effects in Adults Age 70 and Older.

The authors assessed the use, side effects, and outcomes of various antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs), in adults 70 years of age and older by means of a retrospective study of outpatient records. Of these patients (N = 70), 26% improved or recovered. Patients were more likely to improve or recover if they took the antidepressant for at least 3 months. Those on TCAs were as likely to improve or recover and no more likely to discontinue because of side effects than those prescribed SSRIs. Approximately one-third of patients discontinued because of side effects, and SSRI gastrointestinal side effects were more common in patients concomitantly taking nonsteroidal anti-inflammatory drugs. Many older patients who undergo antidepressant therapy discontinue because of side effects; however patients are likely to improve or recover with sustained therapy.