Diagnosis disclosure and advance care planning in Alzheimer disease: opinions of a sample of Italian citizens.

BACKGROUND AND AIMS: In current Alzheimer disease (AD) research there is growing asymmetry between the modest benefits of the currently available treatments, in contrast to the possibility to diagnose AD early in its natural history. This complex situation brings along a number of important ethical issues about diagnosis disclosure and end-of-life decisions that need to be addressed. The principal aim of the study was to investigate the attitudes towards disclosure of a diagnosis of AD and disposition towards completion of advance care planning, in a sample of Italian citizens. METHODS: A convenience sample of 1,111 Italian citizens recruited from a community hospital in Brescia were interviewed using a structured questionnaire with both yes/no and multiple choice format questions about AD. RESULTS: The majority of the sample (83 %) wanted disclosure for themselves. Women and caregivers were significantly less likely to agree that their hypothetically afflicted relative should be informed of a diagnosis of AD. The majority of the sample (81 %) was in favor of advance care planning completion, most of all younger participants and non-caregivers. Less than a third of the sample (24 %) was aware of the existence a judicially appointed guardian for patients affected by dementia. CONCLUSION: The majority of the participants wanted a potential diagnosis of AD to be disclosed to them and to their relatives if they were to be afflicted. The utility of completion of advance care planning and designation of a judicially appointed guardian is frequently endorsed by the sample.

Prestroke dementia: characteristics and clinical features in consecutive series of patients.

BACKGROUND/AIM: The prestroke level of cognitive function should be taken into account in order to predict the impact of stroke on the subsequent risk of dementia. The aim of the present study was to investigate the presence and correlates of prestroke dementia (PSD) as well as to identify its clinical features. METHODS: Premorbid clinical and cognitive features of 158 consecutively recruited patients with a diagnosis of acute cerebrovascular pathology were assessed by interviewing the caregivers using multidimensional assessment. Patients were divided into two groups (PSD group and prestroke nondemented group). Baseline cognitive, functional and behavioral variables and neuroradiological hallmarks (medial temporal lobe atrophy, MTLA) were compared between these two groups. RESULTS: In a logistic regression model, older age (OR 1.05), female gender (OR 2.3), Neuropsychiatric Inventory total score (OR 1.1) and MTLA (OR 1.2) were the variables independently associated with PSD. CONCLUSIONS: These findings support the hypothesis that cognitive impairment in patients with stroke may not only be a direct consequence of the acute cerebrovascular event but also a consequence of underlying neurodegenerative pathology.

Odor identification deficit predicts clinical conversion from mild cognitive impairment to dementia due to Alzheimer's disease.

The aim of this study was to analyze the relationship between olfactory and cognitive functions in subjects affected by mild cognitive impairment (MCI) and to investigate whether olfactory deficits might reflect the likelihood of conversion from MCI to dementia. In this longitudinal study conducted on a sample of MCI outpatients, CA-SIT Smell Identification Test was administered to 88 MCI subjects and 46 healthy control subjects. MCI subjects have been divided into two groups, considering smell identification performances: 40% had normal performances (MCI olfactory-normal), whereas 60% had a moderate olfaction deficit (MCI olfactory-impaired). At 2-year follow-up, the 47% of MCI olfactory-impaired subjects and the 11% of MCI olfactory-normal subjects progressed to dementia. In a logistic regression model, a lower score in MMSE (95%, OR 1.9; IC 1.23-3.01; p = .004) and a pathological smell identification at baseline (95%, OR 5.1; IC 1.16-22.6; p = .03) were independently associated with the progression to dementia within 2 years. This study confirms that smell identification testing may be useful in high-risk settings to identify patients at risk for developing dementia.

The impact of cognitive deficit on self-reported car crashes in ultra-octogenarian population: data of an Italian population-based study.

OBJECTIVE: To examine the usefulness of specific neurocognitive tests for predicting the crash involvement in ultra-octogenarian population. METHODS: A total of 800 subjects (mean age 82.4 + 3.1 years) underwent a battery of neuropsychological tests. Global intellectual functioning was assessed using the Mini Mental State Examination, mental flexibility and information processing speed were assessed using the Trail Making Test parts A and B (TMT-A and TMT-B), long-term memory was evaluated with the short story, and visuo-spatial skills were tested with Clock Drawing Test. One year after this evaluation, 343 (43%) participants have been interviewed by a telephone call to know if they were currently driving and if they had a car crash during this period. RESULTS: Two hundred ninety-seven subjects had their driving license renewed and completed the follow-up 1 year after. Data shows that less than 11% of this group had a car crash during the first year of observation (Crash Involved). Older subjects involved in a car crash showed significant worse performances on TMT-B (TMT-B pathological Crash Involved vs. Noncrash Involved 47% vs. 27%; p = 0.02) and on short story (short story pathological Crash Involved vs. Noncrash Involved 19% vs. 5%; p = 0.02). CONCLUSIONS: Trail Making test B and short story have been demonstrated to provide a predictive value of driving performance of older people. Therefore, we suggest that a simple and standardized battery of neuropsychological tests, lasting about 30 min and administered by an experienced staff, is a good diagnostic instrument for risk prevention of driving activity of older drivers.

Knowledge and attitudes about Alzheimer's disease in the lay public: influence of caregiving experience and other socio-demographic factors in an Italian sample.

BACKGROUND AND AIMS: Despite increasing attention on the knowledge of dementia among patients and family members, little is known about the general public's level of understanding about dementia. The aim of this study was to assess the influence of the caregiving experience, sex and age on the knowledge of AD. METHODS: Eleven hundred and eleven individuals were enrolled. They fulfilled a questionnaire made of 25 questions. The questionnaires were submitted in the waiting rooms of several departments of the Hospital "Spedali Civili di Brescia". The questionnaires assessed several issues, including the general knowledge about Alzheimer's disease, the management and ethical problems. The present study is focused on the analysis of 9 of the 25 questions included in the questionnaire, highlighting aspects about knowledge of symptoms, risk factors, therapies and services. RESULTS: The percentage of correct responses was significantly greater among the caregivers. The group of old respondents gave similar answers, independently of their caregiving status. Women, caregivers or not, are the more knowledgeable group. CONCLUSION: The entire population needs accurate information, but education programs should be specifically tailored for the different sections of the population because they may start with different levels of knowledge.

Changes in characteristics of Alzheimer patients at first visit to centers for dementia: a 10-year follow-up study.

BACKGROUND AND AIMS: The Cronos Project is an observational study on Alzheimer's disease (AD), created by Italy's Ministry of Public Health in 2000. The aim of our study was to evaluate whether the clinical characteristics of patients at their first visit to the Alzheimer Evaluation Unit (UVA) changed from September 2000 to December 2009, and to examine possible reasons for changes noted. METHODS: 1532 consecutive patients were enrolled in two UVAs (September 2000 to December 2009) in a retrospective, descriptive study, with medical records as the primary source of data. RESULTS: Patients' age at the first visit was not different throughout the period of observation. No differences were observed with regard to education or functional characteristics. However, a reduction in the severity of cognitive impairment was found during the period of evaluation: patients consecutively recruited in the first years were more cognitively, functionally, and psycho- behaviorally compromised than patients recruited in the following years. CONCLUSIONS: Data show changes in characteristics at the first visit in patients affected by cognitive deterioration during the years of observation. This finding indicates new clinical needs of patients, requiring changes in pharmacological treatment and in general of the clinical approach.

Does age at observation time affect the clinical presentation of mild cognitive impairment?

BACKGROUND: To date, there are no published data investigating the role of age in the clinical and neuropsychological presentation of mild cognitive impairment (MCI). The aim of the study was to evaluate whether age at the time of evaluation modulates clinical, functional or cognitive profiles in MCI subjects. METHODS: A total of 167 outpatients with a clinical diagnosis of MCI were consecutively enrolled and entered in the study. Clinical and demographic characteristics were carefully recorded. Each patient underwent a wide neuropsychological standardized assessment. RESULTS: MCI subjects were divided into 3 groups according to their age at observation time: 58 MCI patients were classified as young (≤ 69 years), 89 as old (70-79 years) and 20 as very old (≥ 80 years). The 3 groups did not differ in demographic characteristics, general cognitive functions and memory impairment. Very old MCI subjects showed a significantly greater impairment than younger MCI patients in cognitive domains involving executive functions. In particular, very old MCI patients were more frequently classified as having multiple-domain amnestic MCI. CONCLUSION: Present data highlight that the clinical presentation of MCI is affected by age: at presentation, very old MCI subjects show a worse performance than younger MCI subjects on multiple abilities, particularly on executive functions.

Differential impact of apathy and depression in the development of dementia in mild cognitive impairment patients.

BACKGROUND AND AIMS: Neuropsychiatric symptoms may accompany mild cognitive impairment (MCI) and assist in identifying incipient dementia. The aim of this study was to evaluate the role of apathy and depression in the conversion to dementia among MCI subjects. METHODS: 124 MCI outpatients were investigated. Diagnosis of apathy and depression was based on clinical criteria. The main endpoint was the development of dementia within 2 years from the enrolment. RESULTS: 50 (40.3%) subjects were classified as MCI normal, 38 (30.7%) as MCI depressed, 21 (16.9%) as MCI depressed-apathetic and 15 (12.1%) as apathetic. The rates of conversion were 24% for MCI normal, 7.9% for MCI depressed, 19% for MCI depressed-apathetic and 60% for MCI apathetic. Diagnosis of apathy was a risk factor for conversion apart from age, functional and cognitive status at baseline (OR = 7.07; 95% CI 1.9-25.1; p = 0.003). In contrast, MCI depressed subjects had a reduced risk of conversion (OR = 0.10; 95% CI 0.02-0.4; p = 0.001). CONCLUSION: These findings argue for a differential role of apathy and depression in the development of dementia, and suggest the need of dissecting in MCI patients apathy and depression symptoms in the reading of mood disorders.

The importance of Alzheimer disease assessment scale-cognitive part in predicting progress for amnestic mild cognitive impairment to Alzheimer disease.

The aim of this study was to verify the usefulness of Alzheimer Disease Assessment Scale-cognitive subscale (ADAS-Cog), in screening participants at risk of developing Alzheimer disease (AD) among populations with amnestic mild cognitive impairment(aMCI). 98 outpatients with aMCI were recruited. Participants were revaluated after 1 year: 44 (44.9%) were progressed to AD (progressors), while 54 (55.1%) did not convert (nonprogressors MCI). At baseline, cognitive performances were more impaired in progressors assessed by MMSE and by a neuropsychological battery. When tested with the ADAS-Cog subscale, the 2 groups of participants at baseline, progressors, and nonprogressors MCI, were significantly different regarding total score, memory, and nonmemory subitems. Considering a cutoff of 9.5 total score, adjusted for education, ADAS-Cog subscale showed a good performance (area under the curve = 0.67; sensitivity = 0.62%; specificity = 0.73%) in predicting conversion from aMCI to AD. Progressors aMCI were characterized at baseline by a greater cognitive impairment. ADAS-Cog subscale is a useful and brief cognitive assessment tool to screen aMCI participants converting to AD within 1 year.

Acetylcholinesterase inhibitors and depressive symptoms in patients with mild to moderate Alzheimer's disease.

BACKGROUND AND AIMS: Acetylcholinesterase inhibitor (AChEis) therapy in Alzheimer Disease (AD) has been shown to provide cognitive benefits and to slow progression of the disease. AChEis have also been demonstrated to improve behavioral symptoms, although there seem to be subtle differences in the magnitude of response. The aim of our study was to evaluate the effect of 16 weeks treatment with AChEis on depressive symptoms in a selected sample of AD patients in routine clinical practice. SUBJECTS AND METHODS: A study of 135 patients with Alzheimer's disease. All subjects were assessed at baseline (upon initiation of AChEis therapy) and re-evaluated after 16 weeks. RESULTS: At baseline, "Depressed" and "Not depressed" patients were categorized according to DSM IV criteria for depression in Alzheimer Disease. After 16 weeks of treatment with AchEis, we observed an improvement of mood in the "Depressed" patients. In this group "Mood symptoms", measured with GDS, were independently associated with GDS "Mood symptoms" at baseline, but not with improvement on cognition (mean change of MMSE), age or sex. CONCLUSIONS: In depressed AD subjects, AChEis treatment improves depressive symptoms evaluated by GDS. This improvement is independent of cognition enhancement.

Effects of cholinesterase inhibitors appear greater in patients on established antihypertensive therapy.

INTRODUCTION: There is increasing evidence that hypertension may contribute to development of dementia. Studies show that blood pressure lowering therapy might protect against cognitive deterioration and that antihypertensive treatment reduce the incidence of dementia. AIM: We hypothesize that administration of cholinesterase inhibitors (AChEis) to patients with Alzheimer's Disease (AD) receiving antihypertensive medications therapy would result in clinical benefits for a period of 40 weeks in routine clinical practice. METHODS AND MATERIALS: Patients with possible or probable AD were enrolled from 16 Alzheimer evaluation units (UVA) of Brescia and Cremona (Northern Italy). Patients treated with donepezil, rivastigmine and galantamine for 40 weeks independently of dosages were selected. Patients were evaluated at baseline (T0), 4 weeks (T1), 16 weeks (T2) and 40 weeks (T3). RESULTS: 416 patients completed the study at 40 weeks; of these 255 were 'non users' while 161 utilized antihypertensive drugs ('users'). The mean change in MMSE score from baseline to week 40 demonstrate that antihypertensive-treated patients improved by 0.7 points while patients receiving only AChEis remain stables. Analyzing separately patients (n = 183) that ameliorate (responders) on cognition at T3 ( >/= 1 point MMSE score increase) a significant differences in favor of 'users' antihypertensive drugs over 'non users' on cognition at weeks 16 and 40 has been demonstrated. In particular, at T2 the mean change of MMSE from baseline in 'users' was 3.2 +/- 2.6 vs 'non users' 2.2 +/- 2.3 ( p = 0.016) and at T3 was 3.5 +/- 2.5 vs 'non users' 2.0.2.7+/-1.6 ( p = 0.018). Antihypertensive drugs were independently associated with cognitive improvement in responder patients treated with AChEis (95% CI: 0.41-1.79; p = 0.002). CONCLUSION: Antihypertensive medications in AD patients treated with AChEis are associated with an independent improvement on cognition after 40 weeks of treatment.