Physician-assisted suicide laws in Oregon and Washington require the person to have current competency and a prognosis of terminal illness. In The Netherlands voluntariness and unbearable suffering are required for euthanasia. Many people... more
Physician-assisted suicide laws in Oregon and Washington require the person to have current competency and a prognosis of terminal illness. In The Netherlands voluntariness and unbearable suffering are required for euthanasia. Many people are more concerned about the loss of autonomy and independence in years of severe dementia than about pain and suffering in their last months. To address this concern, people could write advance directives for physician-assisted death in dementia. Should such directives be implemented even though, at the time, the person is no longer competent and would not be either terminally ill or suffering unbearably? We argue that in many cases they should be.
Education is needed for enhanced capacity of acute hospitals to provide dementia care. A nonrandomized controlled, repeated-measures design was used to evaluate a dementia education program delivered to an intervention group (IG, n ¼... more
Education is needed for enhanced capacity of acute hospitals to provide dementia care. A nonrandomized controlled, repeated-measures design was used to evaluate a dementia education program delivered to an intervention group (IG, n ¼ 468), compared to a wait-listed group (n ¼ 277), representing separate sites of a multisite hospital. Participants completed self-efficacy for dementia and satisfaction measures and provided written descriptions of dementia care collected at baseline, postintervention (IG only), and at 8-week follow-up. Oral narratives were gathered from IG participants 8 weeks post-intervention. The IG demonstrated significant improvement in self-efficacy scores from baseline to immediately post-intervention (P < .001), sustained at 8 weeks. There were no changes from baseline to 8 weeks postintervention evident in the wait-listed group (P ¼ .21). Intervention group participants described positive impacts including implementation of person-centered care approaches. Implementation of dementia care education programs throughout hospital settings is promising for the enhancement of dementia care.
This essay provides a critical overview of contemporary legal approaches to capacity in the context of dementia. It is a pre-copy edited version of an essay published in Foster, Herring and Doron, The Law and Ethics of Dementia (Oxford:... more
This essay provides a critical overview of contemporary legal approaches to capacity in the context of dementia. It is a pre-copy edited version of an essay published in Foster, Herring and Doron, The Law and Ethics of Dementia (Oxford: Hart Publishing, 2014) pp. 271-282.
Agitation is a common problem in patients suffering from dementia and encompasses a variety of behaviors such as repetitive acts, restlessness, wandering, and aggressive behaviors. Agitation reduces the probability of positive social... more
Agitation is a common problem in patients suffering from dementia and encompasses a variety of behaviors such as repetitive acts, restlessness, wandering, and aggressive behaviors. Agitation reduces the probability of positive social interaction and increases the psychological and organizational burden. While medical interventions are common, there is need for complementary or alternative methods. Music intervention has been brought forward as a promising method to reduce agitation in dementia. While interventions, target groups and research designs differ, there has so far not been a systematic overview assessing the effect of music intervention for agitation in patients with dementia. A meta-analysis was conducted in order to investigate possible effects of music interventions. Twelve studies met inclusion criteria. Music intervention had a medium overall effect on agitation in dementia, suggesting robust clinical relevance. While the moderate number of studies does not allow for further differentiation between sub-types of music intervention, the subgroup comparisons indicated promising pathways for future systematic reviews. This meta-analysis is the first systematic and quantitative overview supporting clinically and statistically robust effects of music intervention on agitation in dementia. The analysis provides further arguments for this non-pharmacological approach and highlights needs for future systematic research reviews for the investigation of intervention types.
CONTEXT: Depression is common in dementia, especially in the early stages, with important clinical implications, but the etiology is unknown and most likely heterogeneous. Antidepressant use in the elderly without dementia has previously... more
CONTEXT: Depression is common in dementia, especially in the early stages, with important clinical implications, but the etiology is unknown and most likely heterogeneous. Antidepressant use in the elderly without dementia has previously been shown to be associated with high risks of adverse events and with structural brain alterations.
OBJECTIVE: To investigate cortical changes associated with depression and antidepressant use in patients with mild Alzheimer's disease (AD) and Lewy body dementia (LBD).
METHODS: 74 subjects with mild AD and LBD from geriatric and psychiatry outpatient clinics in Western Norway were included. The Montgomery-Asberg Depression Rating Scale (MADRS) was used to assess depression. Automatic preprocessing using Freesurfer included steps for white and grey matter surface reconstruction. The resulting cortical thickness was analyzed using linear modeling.
RESULTS: Clusters of depression-associated thinning were found in prefrontal and temporal areas. Treatment-associated thinning was observed in the parahippocampal region and was significant even after correction for age, sex, AD/LBD diagnosis, and MADRS scores.
CONCLUSION: Depression in mild AD and LBD is associated with cortical thinning in prefrontal and temporal areas. The findings suggest that depressive symptoms in mild dementia could develop due to neurodegeneration in the same neural circuits that are critical for depression across different brain disorders. Antidepressant use in patients with mild AD and LBD is associated with parahippocampal thinning. Taken together with low efficacy of antidepressants in cognitively impaired patients and high risks of adverse events, our results suggest a need to re-evaluate the treatment approaches for depression and the role of antidepressants in patients with dementia.
To investigate whether variations within normal ranges of thyroid functioning are related to cognitive and neuropsychiatric functioning in Alzheimer disease (AD). Mild alterations of thyroid hormone levels, even in the normal range, are... more
To investigate whether variations within normal ranges of thyroid functioning are related to cognitive and neuropsychiatric functioning in Alzheimer disease (AD). Mild alterations of thyroid hormone levels, even in the normal range, are associated with changes in mood and cognitive functioning in older, nondemented adults, and lower concentrations of thyroid hormones have been shown to be associated with an increased risk for cognitive decline. Less is known about the relationship between thyroid hormone levels and cognitive and neuropsychiatric dysfunction in AD. Twenty-eight euthyroid patients with AD on donepezil underwent evaluation of thyroid status, including measures of thyroid-stimulating hormone (TSH) and free thyroxine (FT4), and cognitive and neuropsychiatric assessment with the Alzheimer's Disease Assessment Scale, Neuropsychiatric Inventory, and Visual Analog Mood Scales. Correlational analyses indicated statistically significant associations between FT4 concentrati...
INTRODUCTION Cognitive stimulation may be beneficial in slowing the progression of mild neurocognitive disorder (NCD), but the results of existing research are inconsistent. Furthermore, there are no long-term interventions nor individual... more
INTRODUCTION Cognitive stimulation may be beneficial in slowing the progression of mild neurocognitive disorder (NCD), but the results of existing research are inconsistent. Furthermore, there are no long-term interventions nor individual (one-on-one) interventions applied by professionals. Objetive. The aim of this study was to assess the efficacy of a long-term individual cognitive stimulation intervention on people with mild NCD. PATIENTS AND METHODS A pre-post test design with a non-equivalent control group was conducted. A total of 82 participants with mild NCD were assigned to a cognitive stimulation intervention group or to a control group. The intervention consisted of 88 individual format sessions of approximately 45 minutes, twice per week. Independent evaluators assessed cognition, depressive symptomatology and autonomy level in activities of daily living at pre-intervention, intra-intervention (6 months) and post-intervention (12 months). RESULTS At intra- and post-inter...
Project EAR (Environments for Alzheimer’s-friendly Radio) involves working alongside BBC Radio Devon to make the mechanics of radio-broadcasting more dementia friendly. The initial feedback stage was conducted using small sample... more
Project EAR (Environments for Alzheimer’s-friendly Radio) involves working alongside BBC Radio Devon to make the mechanics of radio-broadcasting more dementia friendly. The initial feedback stage was conducted using small sample discussions. There was no standardized questionnaire used, but the general question of “how can we make radio more dementia friendly” was put to people, including some of the answers already provided to give people a starting point for discussions. This information was used to structure the fully-produced 60 minute broadcast on BBC Radio Devon “Music, Memory and Making Radio”. The documentary structure was an unusual mix of music and speaking, with multiple repetitions of the presenters’ names. The topic of the programme was repeatedly explained, mini-features kept as short as possible, and during the recording of interviews, signs were put up asking people to speak clearly. Mini-features included: what makes music memorable, how music can be used to help people with dementias, and initial considerations regarding dementia-friendly radio broadcasts. Below is an overview of the making of the programme; as well as samples of feedback we have been receiving from broadcasters, people living with dementia and their carers.
In this paper, we propose an adaptation of a tool’s validation protocol. We adopted this phases-theory to validate in Italian language an instrument to assess Quality of Life for people with moderate or mild dementia. We will explain the... more
In this paper, we propose an adaptation of a tool’s validation protocol. We adopted this phases-theory to validate in Italian language an instrument to assess Quality of Life for people with moderate or mild dementia. We will explain the example of our Italian validation of DEMQoL-Proxy considering each De Vellis’s phase. We will explain our application of De Vellis’s model to Italian example described. For the first three phases, we reproduced the original validating study in which authors (Smith et al., 2005) defined what to measure, how to generate a set of items and the structure of the scale. Indeed, for the last five phases we explained the adaptation of De Vellis’s model to Italian validation. We hope that this model could be effective for validating goals, for researchers and for all professionals who deal with caregivers and patients with moderate and mild dementia. Furthermore, the measurement of the Quality of Life makes the scale widely useful within the various professi...
Philosophically, the most interesting objection to the reliance on advance directives to guide treatment decisions for formerly competent patients is the argument from the loss of personal identity. Starting with a psychological... more
Philosophically, the most interesting objection to the reliance on advance directives to guide treatment decisions for formerly competent patients is the argument from the loss of personal identity. Starting with a psychological continuity theory of personal identity, the argument concludes that the very conditions that bring an advance directive into play may destroy the conditions necessary for personal identity, and so undercut the authority of the directive. In this article, I concede that if the purpose of a theory of personal identity is to provide an answer to the question What is it for a person to persist over time?, then reflection on personal identity poses a potentially serious threat to the moral authority of advance directives. However, as Marya Schechtman observes, questions about how a single person persists through change are not what most of us are interested in when we think about who a person is. Rather, we are interested in what it means to say that a particular...
Mild cognitive impairment (MCI) often presages development of Alzheimer's disease (AD). We recently completed a cross-sectional study to test the hypothesis that a combination of a brief cognitive screening instrument (Mini-Cog) with... more
Mild cognitive impairment (MCI) often presages development of Alzheimer's disease (AD). We recently completed a cross-sectional study to test the hypothesis that a combination of a brief cognitive screening instrument (Mini-Cog) with a functional scale (Functional Activities Questionnaire; FAQ) would accurately identify individuals with MCI and undiagnosed dementia. The Mini-Cog consists of a clock drawing task and 3-item recall, and takes less than 5 minutes to administer. The FAQ is a 30-item questionnaire completed by an informant. In addition to the Mini-Cog and FAQ, a traditional cognitive test battery was administered, and two neurologists and a neuropsychologist determined a consensus diagnosis of Normal, MCI, or Dementia. A classification tree algorithm was used to pick optimal cutpoints, and, using these cutpoints, the combined Mini-Cog and FAQ (MC-FAQ) predicted the consensus diagnosis with an accuracy of 83% and a weighted kappa of 0.81. When the population was divide...
The current study illustrated the possible positive effects of flavonoids present in the leaves of Mespilus germanica on cognitive performance, learning and memory function in an intra-cerebroventricular streptozotocin-induced Alzheimer’s... more
The current study illustrated the possible positive effects of flavonoids present in the leaves of Mespilus germanica on cognitive performance, learning and memory function in an intra-cerebroventricular streptozotocin-induced Alzheimer’s disease model in male Wistar rats. Five groups (saline-saline control, streptozotocin-saline, and streptozotocin with different doses of flavonoids, 5, 10 and 20 mg/kg) of rats were examined. Rats received different doses of Mespilus germanica flavonoids or saline over three weeks starting one day before surgery. Next, they were assessed using a learning and memory test. After subjected to the behavioral test, the animals were perfused and their brains were fixed with paraformaldehyde 4 % and the tissue was further processed. Finally, the density of intact neurons in the hippocampal CA1 area in all groups was investigated. The results revealed that injection of streptozotocin significantly reduced cognitive function, memory retention as well as CA1 intact neurons compared to the control group. Flavonoids extracted by Mespilus germanica considerably eradicated the negative effects of streptozotocin. Accordingly, Mespilus germanica leaf flavonoids can improve cognitive deficits resulted from injection of streptozotocin.
SYNOPSISAs a part of a survey to study the health and living conditions of the elderly population, a random sample of residents aged 65 and over are examined using the Clinical Interview Schedule (CIS) in order to evaluate their... more
SYNOPSISAs a part of a survey to study the health and living conditions of the elderly population, a random sample of residents aged 65 and over are examined using the Clinical Interview Schedule (CIS) in order to evaluate their psychiatric status. The aim of this study is to evaluate this standard method of assessment as a case-identification instrument in our country. The schedule was completed by 91 subjects. It is easily administered, easily scored, and economical on time. Its completion rate is high. The weighted total scores (WTS) range from 0 to 48. Using the case criteria defined by Cooper & Schwarz (1982), 27 subjects (30%) are considered cases and 64 (70%) are regarded as non-cases. The sensitivity coefficients for the WTS are examined against the overall severity rating at different cut-off points. The optimum cut-off can be anywhere between 16 and 20 points. The WTS has higher validity coefficients to detect the following diagnostic categories (sensitivity, specificity):...
This article presents the development and initial testing of a comprehensive pain chart for the assessment, management and documentation of pain in older people in subacute and residential aged care. The pain chart was developed from... more
This article presents the development and initial testing of a comprehensive pain chart for the assessment, management and documentation of pain in older people in subacute and residential aged care. The pain chart was developed from existing assessment scales and pain indicators, and is targeting needs of older people in residential care and geriatric hospital settings with high prevalence of cognitive impairments. The chart is based on self-report of pain but allows for observation of pain-related behaviours for those unable to report pain. The chart consists of one evaluative and one documentation dimension, and was evaluated by a group of clinicians in geriatric hospital care (n = 15) and residential aged care (n = 6). The chart was found to be content valid, informative and easy to use, facilitating clinical assessments and monitoring, and assisting visual readings of patients’ temporal pain trends.
FDG-PET ([18F]fluorodeoxyglucose positron emission tomography) is frequently used to improve the differential diagnosis of dementia. However, a fundamental methodological issue of the reference area for the intensity normalization... more
FDG-PET ([18F]fluorodeoxyglucose positron emission tomography) is frequently used to improve the differential diagnosis of dementia. However, a fundamental methodological issue of the reference area for the intensity normalization procedure is still unsolved. Here, we systematically compared the two most commonly used normalization methods to the cerebral and to the cerebellar metabolic rate for glucose with regard to detection and differentiation of dementia syndromes. FDG-PET imaging was performed on 19 subjects with early Alzheimer's disease, 13 subjects with early frontotemporal lobar degeneration and 10 subjects complaining of memory impairment, which had not been confirmed by comprehensive clinical testing. Images were normalized to either the cerebral or the cerebellar metabolic rate for glucose. Differences in relative regional glucose metabolism were assessed by voxelwise comparison. Analysis using the two normalization procedures revealed remarkable differential effec...
Background: It has been suggested that the ADAS-Cog is not uniformly sensitive to measuring cognitive decline in Alzheimer disease across mild and moderate patients. As a result, the NTB (neuropsychological test battery) was introduced as... more
Background: It has been suggested that the ADAS-Cog is not uniformly sensitive to measuring cognitive decline in Alzheimer disease across mild and moderate patients. As a result, the NTB (neuropsychological test battery) was introduced as an alternative which measures cognitive de- cline in both mild and moderate patients equally well (Harrison et al, Arch Neurol 64:1323-9, 2007). Methods: The psychometric properties of NTB are examined in two randomized, double-blind trials; one 12-week placebo- and active-controlled (w 350 patients) and the other 24-week placebo-con- trolled (w 330). The test-retest reliability, ratio of within subject variability to between subject variability, and internal consistency of NTB in addition to correlation of NTB with other cognitive and functional measures are evaluated using data from the placebo patients. The sensitivities of NTB and ADAS-Cog are assessed as a function of baseline MMSE (Mini-Mental State Examination) scores using data from the active and the placebo arms. Results: It is confirmed that the NTB has good psychometric properties. Although the NTB and ADAS-Cog are equally sensitive in detecting change in the overall population, differences are observed when stratified by baseline MMSE scores. While the NTB is more sensitive than ADAS-Cog among the mild patients, the reverse is observed among the moderate patients. Conclusions: The NTB has good psychometric proper- ties. Based on two studies of relatively short duration, both the NTB and ADAS-Cog are shown to be good instruments for detecting drug effects on cognitive decline among AD patients. The sensitivity of these instruments needs to be evaluated in validation studies of longer duration.
Early onset dementia (EOD) poses specific challenges and issues for both the patient and (in)formal care. This study explores the use of (in)formal care prior to institutionalization, and its association with patient and caregiver... more
Early onset dementia (EOD) poses specific challenges and issues for both the patient and (in)formal care. This study explores the use of (in)formal care prior to institutionalization, and its association with patient and caregiver characteristics. Participants were part of a community-based prospective longitudinal study of 215 patients and their informal caregivers. Baseline data of a subsample of 215 patient-caregiver dyads were analyzed. Analyses of covariance were performed to determine correlates of (in)formal care use assessed with the Resource Utilization in Dementia (RUD)-Lite questionnaire. Informal care had a 3:1 ratio with formal care. Supervision/surveillance constituted the largest part of informal care. In more than half of cases, patients had only one informal caregiver. The amount of informal care was associated with disease severity, showing more informal care hours in advanced disease stages. Fewer informal care hours were related to more caregiver working hours, e...
Polychlorinated biphenyls (PCB)/polychlorinated dibenzofurans (PCDF) are known to affect central nervous functioning. In recent studies, elderly patients who have been exposed to these have been noted to have psychological deficits. There... more
Polychlorinated biphenyls (PCB)/polychlorinated dibenzofurans (PCDF) are known to affect central nervous functioning. In recent studies, elderly patients who have been exposed to these have been noted to have psychological deficits. There is little known about which test is sensitive to neurotoxins in cognitive evaluation. The objective of the present study was to compare the significance between selective psychological tests in cognitive assessment in PCB-laden elderly. A retrospective PCB/PCDF exposed cohort was observed. Exposed elderly aged ≥ 60 years and registered in Central Health Administration were enrolled, and similar age- and sex-matched subjects served as non-exposed controls. The Mini-Mental State Examination (MMSE) and Attention and Digit Span (ADS) were tested in both groups. Student's t-test, χ(2) -test and linear regression models were used for statistical analysis. A total of 165 exposed patients and 151 controls were analyzed. The exposed group included 49% ...
Diet may be associated with risk of dementia and Alzheimer disease (AD). The authors examined the association between fruit and vegetable consumption in midlife and risk for all types of dementia and AD. Participants were 3,779 members of... more
Diet may be associated with risk of dementia and Alzheimer disease (AD). The authors examined the association between fruit and vegetable consumption in midlife and risk for all types of dementia and AD. Participants were 3,779 members of the Swedish Twin Registry who completed a diet questionnaire approximately 30 years before cognitive screening and full clinical evaluation for dementia as part of the study of dementia in Swedish Twins (HARMONY) study. Among the participants, 355 twins were diagnosed with dementia. Among these, 81 twin pairs were discordant for dementia (50 discordant for AD). Data were analyzed with logistic regression for the entire sample using generalized estimating equations to adjust for relatedness of twins and with conditional logistic regression for the co-twin control design. In fully adjusted models, a medium or great proportion of fruits and vegetables in the diet, compared with no or small, was associated with a decreased risk of dementia and AD. This...