Pharmaceutical consumption and cost in patients with dementia: A longitudinal study by the Registry of Dementias of Girona (ReDeGi) in Catalonia (Spain).

OBJECTIVE: Drug spending increases exponentially from the age of 65-70 years, and dementia is one of the diseases significantly contributing to this increase. Our aim was to describe pharmaceutical consumption and cost in patients with dementia, using the Anatomical Therapeutic Chemical (ATC) classification system. We also assessed the evolution of costs and consumption, and the variables associated to this evolution during three years. METHODS: Three years prospective cohort study using data from the ReDeGi and the Health Region of Girona (HRG) Pharmacy Unit database from the Public Catalan Healthcare Service (PCHS). Frequency of consumption and costs of ATC categories of drugs were calculated. RESULTS: Sample of 869 patients with dementia, most of them with a diagnosis of degenerative dementia (72.6%), and in a mild stage of the disease (68.2%). Central nervous system (CNS) drugs had the highest consumption rate (97.2%), followed by metabolic system drugs (80.1%), and cardiovascular system drugs (75.4%). Total pharmaceutical cost was of 2124.8 € per patient/year (standard deviation (SD)=1018.5 €), and spending on CNS drugs was 55.5% of the total cost. After 36 months, pharmaceutical cost increased in 694.9 € (SD=1741.9), which was associated with dementia severity and institutionalization at baseline. CONCLUSIONS: Pharmaceutical consumption and costs are high in patients with dementia, and they increase with time, showing an association with baseline dementia severity and institutionalization. CNS drugs are the pharmaceuticals with highest prescription rates and associated costs.

Prevalencia y evolución del delirium en una muestra comunitaria de 70 años y más / Prevalence and evolution of delirium in a community population of 70 years and older

Introducción. Existen numerosos estudios sobre el delirium con muestras clínicas e institucionalizadas, pero son escasos con muestras comunitarias. El objetivo del estudio fue determinar la prevalencia de delirium en una muestra comunitaria y la supervivencia en un período de 5 años. Método. Estudio de casos y controles y de supervivencia a partir de los datos de un estudio epidemiológico para determinar la prevalencia de demencia y su incidencia tras 5 años en ocho municipios de la provincia de Girona. Se aplicaron criterios DSM-IV para identificar los casos de delirium en el estudio de prevalencia a partir de la información recogida mediante el Cambridge Mental Disorders of the Elderly Examination. Se aplicaron técnicas de contraste de hipótesis para comparar las características de los participantes según la presencia o ausencia de delirium. Se utilizó la técnica de Kaplan- Meier para estimar la supervivencia de los participantes y un modelo de regresión multivariante de Cox para determinar el efecto del delirium sobre la mortalidad a los 5 años. Resultados. Participaron 1.460 habitantes mayores de 69 años y se detectaron 14 casos de delirium que representaron una prevalencia del 0,96 % (intervalo de confianza [IC] 95%: 0,43-1,49). La supervivencia media para los participantes con delirium fue de 3 años (IC 95%: 1,9-4,1) y fue significativamente inferior a la de los controles sanos. La presencia de delirium incrementó en 2,65 el riesgo de mortalidad a los 5 años. Conclusiones. La prevalencia de delirium en muestras comunitarias es baja y la mayoría de los casos está superpuesto a una demencia. Los pacientes con delirium tienen un mayor riesgo de mortalidad a los 5 años (AU)

Introduction. There are many studies on delirium in clinical populations and nursing home patients but not in community populations. This study has aimed to know the prevalence of delirium in a community population and to know the survival rate during a five-year period. Method. Case-control and survival study based on data from an epidemiological study to measure the prevalence and incidence of dementia in eight rural villages in Girona. According to the Diagnostic and Statistical Manual of Mental Disorders, delirium was identified for the prevalence study using the information obtained from the Cambridge Mental Disorders of the Elderly Examination. A hypothesis contrast method was used in order to compare all clinical features of the subjects according the presence or the absence of delirium. The Kaplan-Meier technique was used to estimate survival of the subjects, and a multivariate Cox regression analysis was done to know the effect of delirium on mortality over the five-year period. Results. 1,460 subjects older than 69 participated in the study. A prevalence of 0.96% (95% confidence interval [CI]: 0.43-1.49) was detected (14 cases of delirium). Mean survival for subjects with delirium was 3 years (CI 95%: 1.9-4.1) and it was slightly lower than for heal - thy controls. The presence of delirium increased the risk of death in five years by 2.65. Conclusion. The prevalence of delirium in community populations is low and most of the times it is superimposed on dementia. Patients with delirium have a higher risk of mortality at the end of a five-year period (AU)

[Prevalence and evolution of delirium in a community population of 70 years and older]. / Prevalencia y evolución del delirium en una muestra comunitaria de 70 años y más.

INTRODUCTION: There are many studies on delirium in clinical populations and nursing home patients but not in community populations. This study has aimed to know the prevalence of delirium in a community population and to know the survival rate during a five-year period. METHOD: Case-control and survival study based on data from an epidemiological study to measure the prevalence and incidence of dementia in eight rural villages in Girona. According to the Diagnostic and Statistical Manual of Mental Disorders, delirium was identified for the prevalence study using the information obtained from the Cambridge Mental Disorders of the Elderly Examination. A hypothesis contrast method was used in order to compare all clinical features of the subjects according the presence or the absence of delirium. The Kaplan-Meier technique was used to estimate survival of the subjects, and a multivariate Cox regression analysis was done to know the effect of delirium on mortality over the five-year period. RESULTS: 1,460 subjects older than 69 participated in the study. A prevalence of 0.96% (95% confidence interval [CI]: 0.43-1.49) was detected (14 cases of delirium). Mean survival for subjects with delirium was 3 years (CI 95%: 1.9-4.1) and it was slightly lower than for heal - thy controls. The presence of delirium increased the risk of death in five years by 2.65. CONCLUSION: The prevalence of delirium in community populations is low and most of the times it is superimposed on dementia. Patients with delirium have a higher risk of mortality at the end of a five-year period.

[CAMDEX-R in the clinical evaluation of dementias]. / El CAMDEX-R en la evaluación clínica de las demencias.

CAMDEX has been very useful both for clinical use as epidemiological enquiries about dementia. However, the knowledge evolution about means that nowadays this schedule shows several shortcoming. A new version, CAMDEX-R, has adapted and introduced enough items to satisfy the actual requirements. The present article describes the changes and new contributions accomplished on the schedule.

[Integrated program of psychogeriatric care]. / Programa integral de atención psicogeriátrica.

INTRODUCTION: At the present time there is considerable controversy over the course to follow in attention to patients with psychogeriatric disorders. Rapid diagnosis and maintaining the patients in their homes are the basic objectives of the policy of sharing responsibility among those involved. DEVELOPMENT: We review the bibliography and suggest a form of attention based on experience acquired in the dementia evaluation unit of the Programme Vida als Anys of the Generalitat de Catalunya. The model described is based on making the diagnosis in the patient's home, giving support to the family and integrating the patient into a follow-up unit, with a person responsible for evaluating and resolving the needs of both patient and family as they arise. In order to carry out this programme, the attention must be given by multidiscliplinary units with the necessary resources.

[The prevalence of dementias in a rural area. A study in Girona]. / Prevalencia de demencias en una zona rural. Estudio de girona.

OBJECTIVES: To know the prevalence of dementia and its subtypes in our area. PATIENTS AND METHODS: Epidemiological study, door-to-door, double phase, in which all non-institutionalized subjects from 8 rural villages aged 70 and more were selected. The general physicians and nurses, previously trained, administered the Mini Cognitive Examination (MCE) in the first phase. All subjects to whom cannot been administered MCE due to illness or sensorial deficit, all subjects under the cut-off point and a similar number of subjects randomized among the ones over the cut-off point, get through the second phase in which a clinical psychologist and a neurological trained physician administered the Cambridge Mental Disorders of the Elderly Examination (CAMDEX). All diagnosis were done under CAMDEX criteria. RESULTS: A total of 1,460 subjects participated. The prevalence of dementia was 16.3% (14.4-18.2). The dementia Alzheimer type ratio was 40.76% (34.5-47), the vascular dementia was 38.24% (32.1-44.4), the mixed dementia was 11.7% (7.7-15.8) and the secondary dementia was 9.2% (5.5-12.9%). The logistic regression confirms that age and female sex are dementia risk factor. CONCLUSION: In our geographical area a very high prevalence of dementia is found.

Prevalencia de demencias en una zona rural. Estudio de Girona / The prevalence of dementias in a rural area. A study in Girona

Objetivos. Conocer la prevalencia de demencia y de sus subtipos en una zona rural de la provincia de Girona. Pacientes y métodos. Estudio epidemiológico, puerta a puerta, realizado en dos fases, para el cual se seleccionaron todos los sujetos no institucionalizados de 70 y más años censados en ocho municipios rurales. Los médicos de cabecera y los diplomados en enfermería de estos municipios, previamente entrenados, administraron el miniexamen cognitivo (MEC) en la primera fase. Todos los sujetos a los que no se les pudo administrar el MEC por enfermedad o por déficit sensoriales, todos los que puntuaron por debajo del punto de corte y un número similar de sujetos elegidos al azar entre el grupo que obtuvieron puntuaciones por encima del punto de corte, pasaron a la segunda fase en la que un psicólogo clínico y un médico entrenado en neurología suministraron el Cambridge Mental Disorders of the Elderly Examination (CAMDEX).Todos los diagnósticos se han efectuado según los criterios del CAMDEX. Resultados. Participaron un total de 1.460 sujetos. La prevalencia de demencia fue del 16,3 por ciento (14,4-18,2). La proporción de demencia tipo Alzheimer fue del 40,76 por ciento (34,5-47,0), la demencia vascular del 38,2 por ciento (32,1-44,4), la demencia mixta del 11,7 por ciento (7,7-15,8) y la demencia secundaria del 9,2 por ciento (5,5-12,9). La regresión logística determina que la edad y el sexo femenino son factores de riesgo de demencia. Conclusión. En nuestra zon (AU)

Programa integral de atención psicogeriátrica / Integral programme of psychogeriatric healthcare

Introducción. Actualmente, existe una gran controversia sobre la política sanitaria a seguir en la asistencia de pacientes con trastornos psicogeriátricos. El diagnóstico rápido y la contención de los pacientes en el domicilio son los objetivos fundamentales dentro de una política de responsabilidad compartida entre diversos estamentos. Desarrollo. Se lleva a cabo una revisión de la bibliografía y se lanza una propuesta asistencial basada en la experiencia acumulada en la unidad de valoración de las demencias del Programa Vida als Anys de la Generalitat de Catalunya. El modelo expuesto se basa en la realización del diagnóstico a domicilio, apoyo a la familia e integración del paciente dentro de una unidad de seguimiento, con un responsable que valorará y dará soluciones a las necesidades puntuales del paciente y la familia a lo largo de la evolución de la enfermedad. Para que el programa pueda realizarse es preciso que la asistencia sea realizada por unidades multidisciplinarias y se disponga de los medios de soporte necesarios (AU)

[Depression and dementia: case-control study]. / Depresión y demencia: estudio caso-control.

OBJECTIVE: To know the prevalence and risk factors for depression in demented patients. PATIENTS AND METHODS: From a field epidemiological study, in a double phase, door to door, in which 1,460 subjects older than 69 from a rural area participated, three groups were established: group A made up of 200 dementia diagnosed subjects; group B made up of 119 subjects without dementia but with punctuation on the screening instrument (MEC) under the cut off point; the 283 subjects on the group C were not catalogued as demented, and the MEC punctuation was over the cut off point. Both the diagnoses of dementia and depression were made in basis of CAMDEX criteria. RESULTS: The frequency of depression in groups A, B and C was 26.5%, 11.76% and 4.94%, respectively. The dementia is a risk factor for depression (OR: 4.81; CI: 2.93-7.91). There are no differences in the frequency of depression according to dementia subtypes. Sex, age, marital status and severity of dementia do not have an influence on the prevalence of depression. The presence of psychiatric history is a risk factor for depression on groups A and B, but not for C. CONCLUSION: Depressions are more common on subjects with cognitive impairment.

[Non cognitive symptoms in dementias]. / Síntomas no cognitivos en las demencias.

In the phenomenology of dementia, the cognitive symptoms surround most of the interests both for investigators as clinicians. However, the non cognitive symptoms are shown so often they should become a major one in the clinical evaluation of the dementia syndrome. Moreover, the presence of this symptoms means more clinical severity, increases the institutionalization risk and causes a larger emotional burden for demented carers. On this work, the authors argue about the possible physiopathogenic causes related to cognitive and non cognitive aspects of dementia.

[The Neuropsychiatric Inventory. Psychometric properties of its adaptation into Spanish]. / Neuropsychiatric inventory. Propiedades psicométricas de su adaptación al español.

OBJECTIVE: The purpose of this study was to examine the reliability and validity of the Spanish (Spain) version of the Neuropsychiatric Inventory. PATIENTS AND METHODS: The Neuropsychiatric Inventory was administered to the caregivers of 63 subjects from the Dementia Unit, Hospital Santa Caterina, Girona. All patients had detailed neuropsychological assessment, and their non-cognitive symptoms were also examined with the CAMDEX. RESULTS: There was a high level of internal consistency reliability. The Neuropsychiatric Inventory subscores correlated with those of the CAMDEX, indicating an acceptable level of validity. The most frequent symptom was apathy (56%), followed by irritability (38%), depression/dysphoria (35%), aberrant motor behavior (30%), agitation/aggression (29%), anxiety (27%), disinhibition (24%), delusions (19%), hallucinations (14%) and euphoria (3%). CONCLUSIONS: This study showed that the Spanish version of the Neuropsychiatric Inventory is a reliable instrument, which can briefly assess non-cognitive symptoms in demented patients. The Neuropsychiatric Inventory is a useful instrument for research and clinical practice in different culture around the world.

[Treatment for non-cognitive symptoms in Alzheimer's disease]. / Tratamiento de los síntomas no cognitivos en la enfermedad de Alzheimer.

OBJECTIVES: To review the classical treatment for non cognitive symptoms in Alzheimer's disease and to estimate the possible future contributions. DEVELOPMENT: The non cognitive symptoms, with a high frequency in dementia, mean a larger clinical severity, an increment of institutionalization and a larger carer's emotional burden. Several treatment frequently used has been reviewed (antipsychotic, antidepressant, antianxiety, anticonvulsive...) and the response for some of this symptoms is relatively narrow and side effects are frequent and intense. New drugs, as cholinesterase inhibitors and cholinergic agonist, that have demonstrated their efficacy for the cognitive symptoms, seem to be also effective for non cognitive ones. CONCLUSION: The relative low effectivity of classical treatment and the frequency and intensity of side effects open new possibilities to cholinesterase inhibitors in the treatment of non cognitive symptoms in Alzheimer's disease.

[The Cambridge Cognitive Examination as a tool for detection of dementia]. / El Cambridge Cognitive Examination como instrumento de detección de demencia.

INTRODUCTION: The efficiency of Cambridge Cognitive Examination' (CAMCOG) is analyzed as a tool to detect dementias in epidemiological studies. PATIENTS AND METHODS: The data were obtained from subjects who enrolled the second phase on a door-to-door field epidemiological study. The tool used was the 'Cambridge Mental Disorders of the Elderly Examination' (CAMDEX). RESULTS: From the total sample of 602 subjects, 189 (31%) were men and the remaining 413 (69%) were women. The age average was 77.21 +/- 6.18 for the men group and 78.76 +/- 5.98 for the women group. The cut-off point that obtained best efficacy was 59/60. A multiple regression analysis was made using CAMCOG total scoring as the dependent variable and clinical diagnosis, age, sex and scholarship as independent variables. All the variables intermediate on CAMCOG total scoring with a multiple correlation coefficient (R) of 0.7061 (p < 0.0000). Five of the twelve CAMCOG subareas were efficient with a significance level of p > 0.0000, classifying correctly the 82.56% of the subjects. CONCLUSION: The CAMCOG is a moderate efficient total to discriminate dementia from no dementia on epidemiological studies.

[Cognition and depression]. / Cognición y depresión.

OBJECTIVES: To find the relationship between cognitive deterioration and the symptoms of depression. PATIENTS AND METHODS: A sample from the community of 602 persons, 200 of whom had been diagnosed as having dementia and 81 depression. Cognitive deterioration was evaluated using the CAMLOG and the depressive symptoms by means of the CAMDEX depression scale. RESULTS: On multiple regression analysis it was observed that the CAMLOG did not influence the results on the depression scale. Similarly, on ANOVA it was seen that the diagnosis of depression did not influence the results of CAMLOG either. CONCLUSIONS: Cognitive deterioration does not affect depressive symptoms, nor does depression affect cognitive function.

[Non-cognitive aspects of dementia]. / Aspectos no cognitivos de las demencias.

OBJECTIVE: To observe the frequency of various psychiatric disorders (depressive disorders, anxiety state and paraphrenic-paranoid disorders). PATIENTS AND METHODS: This study includes the 'cases' of dementia detected in an epidemiological field study done door-to-door, double phased and including non-institutionalized persons aged over 69 years in a rural area. All diagnoses were done by CAMDEX and on these criteria. RESULTS: Depressive disorder was diagnosed in 26.5% studied, paraphrenic or paranoid disorder in 14% and anxiety state in 6.5%. Depression and paraphrenic-paranoid disorder were not associated with the severity of the dementia, whilst anxiety state was more commonly seen in mild dementia. Paraphrenic-paranoid disorders were commoner in women than in men. CONCLUSION: The considerable prevalence of other psychiatric diagnoses in persons with dementia shows that non-cognitive symptoms are common in these patients.

[Prevalence of depressive disorders in dementia]. / Prevalencia de trastornos depresivos en demencias.

OBJECTIVE: To find the prevalence of depressive illness associated with dementia in our geriatric population. MATERIAL AND METHODS: A study was made of the entire population aged over 69 years in eight rural districts of the province of Girona (Spain). Diagnosis was made using CAMDEX criteria. RESULTS: The prevalence of depression (depressive disorders plus pseudo dementia) was 9.1% (IC = 7.6-10.5%). In the group of patients with dementia, the frequency of depression was 28.15% whilst in the group with no dementia it was 5.4% (p = 0.0000). No differences were seen in the prevalence of depression between patients with Alzheimer type dementia (ATD) and those with vascular dementia (VD). The gravity of dementia, sex and age did not influence the frequency of depression. CONCLUSIONS: Depression in patients with dementia was very frequent in our geriatric population. Dementia was seen to be a risk factor with regard to depression.

The Mini Cognitive Examination for screening in epidemiologic studies of dementia.

We assessed the efficiency of the Mini Cognitive Examination (MCE) for detecting dementia and studied the influence of certain variables (age, sex, education) on its global rating. The study was carried out on a rural population in two stages: the MCE was administered in the first stage, whilst the Cambridge Mental Disorders of the Elderly (CAMDEX) was given in the second. The sensitivity of the MCE was 93.5% and specificity was 82%. Multivariate statistical analysis showed that the age, sex and education all had significant impacts on the MCE global rating. Out of 13 MCE items, only nine (temporal orientation, spatial orientation, calculation, repetition of a sentence, inverting the order of 3 numbers, sequence of praxic orders, abstraction and naming of objects) discriminated between subjects with dementia and controls. The MCE proved to be a highly efficient screening instrument for dementia.

The prevalence of dementia in Girona.

To provide a preliminary assessment of the prevalence of dementia and its subtypes in a rural area. From a total of 2,469 people over 65 who were not committed to any institution, 273 were randomly chosen and stratified by age and sex. Of these 273 individuals, 244 (89.4%) took part in the study. Family doctors administered the miniexamen cognoscitivo (MEC), a Spanish version of the Mini Mental State Exam to screen all individuals taking part in the first phase. Enrolled in the second phase were all those whose scores on the MEC were below the cut-off point, plus a similar number of individuals whose scores were above this level and who were used as controls. The CAMDEX was the instrument used for diagnosis by clinical psychologists. The overall prevalence of dementia in the area under study was 13.93 +/- 4.34%. This prevalence includes the three levels of diagnosis certainty for CAMDEX (definitive, probable and possible) and the three levels of severity (minimum, mild, moderate, and severe) defined by the instrument. The number of individuals with dementia increased with age. Females showed more dementia than males in all age groups. The distribution of dementia by subtypes was 41.18% for both Alzheimer's type senile and presenile forms, and for vascular dementia, and 17.64% for mixed dementia. Our results show a prevalence of dementia that is higher than rates observed in other studies using similar materials and methods.

The efficiency of CAMDEX in the diagnosis of dementia and its sub-types.

AIMS: To determine the ability of the Cambridge Mental Disorders of the Elderly Examination (CAMDEX) to differentiate between healthy patients and those suffering from dementia or depression. To validate its efficiency in the diagnosis of different dementia sub-types. To determine inter-examiner reliability. MATERIAL AND METHOD: A neurologist and a psychiatrist used DSM-III-R and ICD-10 criteria to independently select 13 patients suffering from Alzheimer-type primary degenerative dementia, 9 patients with multi-infarct dementia, 10 with secondary dementia, 14 with serious depression and 18 who were free of any type of dementia or depression to be used as controls. All these individuals were interviewed by a clinical psychologist using CAMDEX. The interviews of 41 were carried out by 3 teams of psychologists with CAMDEX experience. While 1 psychologist directed the interview, another acted as an observer who independently recorded answers. RESULTS: The overall agreement levels between clinical and CAMDEX diagnoses was kappa = 0.825. The ability of CAMDEX to differentiate between patients with dementia and those who were depressed or controls was perfect (kappa = 1). On the other hand, the diagnostic agreement for the different dementia sub-types was kappa = 0.733. There was a very high level of agreement between the interviewer and observer for the various scales that make up the CAMDEX (p < 0.001). There was complete agreement on diagnoses (Phi = 1). CONCLUSIONS: CAMDEX is an excellent instrument for the diagnosis of dementia and its sub-types, offering excellent inter-examiner reliability.

[Validation of the Spanish version of the Severe Impairment Battery]. / Validación de la adaptación española de la Severe Impairment Battery (SIB).

We examine the cognitive ability of 58 demented patients who were evaluated with the Spanish version of the Severe Impairment Battery (SIB). The SIB is composed of multiple simple subtests for memory, language, orientation, attention, visual perception and ability to construct. The battery also assesses social skills, praxis and the ability to respond appropriately to name. The mean SIB scores (72.55 +/- 17.99; range 8-99) correlated with mean scores (10.76 +/- 6.41; range 0-31) on the Spanish version of Folstein's Mini-Mental State Examination (MMSE). The SIB detected deterioration in the nine cognitive areas examined, even in the most severely impaired patients (MMSE = 0-6). These results indicate that the Spanish version of the SIB is a useful instrument for examining severely demented patients.