Economic evaluation of donepezil in moderate to severe Alzheimer disease

OBJECTIVE

To investigate the costs to society of Alzheimer disease (AD) care in a multinational, randomized, placebo-controlled trial of donepezil in patients with moderate to severe AD.

METHODS

A total of 290 patients with AD (screening standardized Mini-Mental State Examination score 5 to 17) were randomized to receive either donepezil (n = 144; 5 mg/day for 28 days, followed by 10 mg/day as per clinician's judgment) or placebo (n = 146) for 24 weeks. The authors collected data on patient and caregiver health resource utilization prospectively using the Canadian Utilization of Services Tracking questionnaire. Costs were calculated for patients and caregivers in each group based on resource utilization multiplied by the unit prices for each resource. A cost (the average Ontario minimum wage for 1998 [Can 6.85 dollars per hour]) was assigned to unpaid time that caregivers spent assisting the patient with activities of daily living (ADL).

RESULTS

Patient and caregiver demographics at baseline were similar across the two groups. After adjusting for baseline total cost per patient, the mean total societal cost per patient for the 24-week period was donepezil, Can 9,904 dollars (US 6,686 dollars) and placebo, Can 10,236 dollars (US 6,910 dollars). This net cost saving of Can 332 dollars (US 224 dollars) included the average 24-week cost of donepezil treatment. Most of the cost-saving with donepezil treatment was due to less use of residential care by patients, and caregivers spending less time assisting patients with ADL.

CONCLUSION

This cost-consequence analysis reveals economic benefits of treatment of moderate to severe AD with donepezil.

Behavioral symptoms in mild cognitive impairment

The authors investigated neuropsychiatric symptoms in mild cognitive impairment (MCI) from baseline data of the Investigation in the Delay to Diagnosis of AD with Exelon (InDDEx) study (n = 1,010). Neuropsychiatric symptoms were reported in 59% of subjects (Neuropsychiatric Inventory [NPI]). NPI+ subjects had significantly greater impairment on global, cognitive, and functional scores than NPI- subjects. The presence of neuropsychiatric symptoms appears to be a marker of MCI severity.

Inter-rater reliability in assigning ICF codes to children with disabilities

PURPOSE

The purpose of this study was to determine if independent raters would arrive at similar decisions about which codes from the Activities and Participation component of the International Classification of Functioning, Disability, and Health (ICF) to assign to children with disabilities based on the results of standard paediatric functional assessment measures.

METHOD

Children (N = 60), 9 months to 17.75 years old, with a range of disabilities were assessed using either the Vineland Adaptive Behavior Scales (n = 20), the Pediatric Evaluation of Disability Inventory (PEDI) (n = 20), or the School Function Assessment (SFA) (n = 20). Two raters independently determined which of 40 codes from the Activities and Participation component of the ICF applied to each child based on items and standard scores from the assessment measure. The Cohen's kappa statistic was used as the measure of inter-rater reliability.

RESULTS

The kappa statistic was >/= 0.70, the criterion for good agreement in this study, for 23/40 codes using the Vineland, 17/40 codes using the PEDI, and 17/40 codes using the SFA. The mean kappa statistic reached >/= 0.70 for the Self care domain, using all three tools. The mean kappa statistic also reached >/= 0.70 for Learning and Applying Knowledge and Mobility using the Vineland.

CONCLUSIONS

Independent raters reached high rates of agreement when assessment test items were structured developmentally and corresponded to a single ICF code. For domains other than Self care, alternative assessment strategies may be necessary to improve assigning ICF codes to children with disabilities.

Neurofilament inclusion body disease with early onset frontotemporal dementia and primary lateral sclerosis

A small number of patients have recently been described with a sporadic neurodegenerative disease, associated with the neuropathological finding of neurofilament-immunoreactive neuronal inclusions. The clinical and pathological spectrum of this new disease entity has yet to be fully defined. We describe an additional case of "neurofilament inclusion body disease" (NIBD) with several unusual features. This young woman, who suffered from rapidly progressive frontotemporal dementia (FTD) and features of primary lateral sclerosis (PLS), died at age 29. Neuropathological examination disclosed numerous neuronal cytoplasmic inclusions in many regions of the central nervous system. The inclusions varied in morphology with some being immunoreactive for ubiquitin while others showed strong positivity for neurofilament proteins. Intranuclear neuronal inclusions were also present. There was no significant tau or alpha-synuclein pathology. There was severe degeneration of the corticospinal tracts but lower motor neurons were normal in number and morphology. This case confirms that NIBD should be considered in the differential diagnosis of FTD, particularly in young patients. In addition, it extends the clinical phenotype of NIBD to include PLS and better defines the anatomical distribution and morphology of the pathological lesions.

[Results of the international hemodialysis study DOPPS in Spain and Europe]

The Dialysis Outcomes and Practice Pattern Study (DOPPS) is an international observational study of treatment conditions and medical outcomes in hemodialysis patients. Prospective sampling has yielded long-term observational data from randomly selected groups of patients receiving treatment at representative, randomly selected hemodialysis units in each country. The data shown were collected at 20 hemodialysis units/centers in Spain. The data pertaining to Spain--Sp--refers to 575 patients and their comparison with those of the Euro-DOPPS countries--Eu--(Germany, France, United Kingdom, Italy and Spain), which encompass 3,038 patients, represent the formal goal of this paper. Diabetes mellitus, at 21.5% in Eu and 21.7% in Sp, was the most common cause of renal insufficiency in dialysis and coronariopathy, as a concomitant disease, was present in 67.8% in Eu as opposed to 75.8% in Sp. Differences were observed in the incident of hypertension (73.4% in Eu vs 77.4% in Sp), hepatitis C (11.6% vs 19.5%), depression (12.7 vs 16.2%) and left ventricular hypertrophy (54.9% vs 62.3%). The patterns of vascular access were similar (79% vs 81% AV fistulas in Eu and Sp, and 10% synthetic grafts for both) and the mean applied dose of dialysis--Kt/V--smaller (1.19) in Sp than in Eu (1.24); likewise the duration of the dialysis (in minutes) was shorter (234 in Eu vs 217 in Sp) and the % of synthetic membranes used was smaller (60% in Eu vs 52% in Sp). There were no differences between the groups in the figures for urea, creatinine, albumin, nPCR, calcium, phosphate or PTH. There were also no differences in the mean values of Hb (10.7 for Eu vs 10.8 for Sp), given that the values of ferritin were noticeably lower in Sp (288 vs 355) and the dose of EPO/kg/week was higher to in Sp (115 vs 102); s.c. route was used in similar proportions (69% in Eu vs 67% in Sp). The level of medical care, understood as contact with the physician at all or almost all treatments, was noticeably better in Sp (90%) that in Eu (66%), whereas the number of patients per hour of specialized personnel and % of specialized staff, were smaller. Mortality (death/100 patients-years) was one point lower in Sp than in Eu (15.4 vs 16.3). These data suggest that an increment in dialysis time and in the percentage of synthetic membranes used, as well as in the supply of intravenous iron, would be justified.

A Canadian cohort study of cognitive impairment and related dementias (ACCORD): study methods and baseline results

The overall objective of the Canadian Collaborative Cohort of Related Dementias (ACCORD) study is to describe the diagnostic distribution, natural history and treatment outcomes of individuals referred from the community to dementia clinics in Canada. Between 1997 and 1999, an inception cohort of 1,136 subjects entered into this longitudinal study. At the baseline assessment, 10.9% of the subjects were classified as "not cognitively impaired" (NCI), 30.1% as "cognitively impaired not demented" (CIND), and 59% as demented. A subclassification of CIND included amnestic 25.1%, vascular cognitive impairment 18.1%, psychiatric 17.2%, neurologic 7.3%, medical/toxic metabolic 3.5%, mixed 7.6% and not specified 19.0%. The percentage of the cohort referred with dementia increased progressively each decade, while the proportions of CIND and NCI decreased. Within the dementia group, Alzheimer's disease accounted for 47.2% of the subjects, mixed dementias 33.7%, vascular dementia 8.7%, frontotemporal degenerations 5.4%, dementia with Lewy bodies 2.5%, and unclassifiable 1.8%. The ACCORD cohort will allow a detailed study of the longitudinal course of CIND, and the longer-term outcomes of both treated and untreated dementia subjects.

Indomethacin for the treatment of Alzheimer's disease patients

BACKGROUND

Inflammatory processes involving cytokines, prostaglandins, free radicals and glial cells have been implicated in the pathogenesis of Alzheimer's disease. Non-steroidal anti-inflammatory drugs such as indomethacin attenuate inflammatory reactions. Hence, there may be a role for some of these drugs in the treatment of Alzheimer's disease.

OBJECTIVES

To examine the efficacy of indomethacin in the treatment of patients suffering from Alzheimer's disease.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (which contains records from many different medical and trials databases) on 14 June 2001 using the terms indomethacin and indome* and NSAIDS. In addition two independent reviewers systematically searched relevant computerized databases and Internet sites. This was supplemented by hand searching and additional references sought from selected papers.

SELECTION CRITERIA

Single or multi-centre placebo-controlled randomized trials examining the efficacy of indomethacin in patients diagnosed with Alzheimer's disease were eligible for selection for this review. Using a standard extraction form, inclusion/exclusion criteria were set to ensure design quality and lack of bias of all trials included.

DATA COLLECTION AND ANALYSIS

Data were collected independently by two reviewers and any discrepancies were subject to discussion. Corresponding authors were contacted for any missing data needed for statistical analysis.

MAIN RESULTS

Only one study was selected for this review (~~Rogers 1993~~). We detected no statistically significant difference between indomethacin treatment and placebo for the individual cognitive tests, Mini Mental State Examination (MMSE), Alzheimer's Disease Assessment Scale ( ADAS), Boston Naming Test (BNT) and Token Test (TK). Dropouts and death rate were the only reported results that were amenable to evaluation. The dropout rate was higher in the indomethacin group (10/24) than in the control group (6/20). Gastrointestinal adverse events were more prevalent in the treatment group (5/24 compared with 1/20 in control group). There was no statistically significant difference in death rate between the two groups (p=0.9).

REVIEWER'S CONCLUSIONS

On the basis of this one trial and subsequent analysis of data as reported by the authors, indomethacin cannot be recommended for the treatment of mild to moderate severity Alzheimer's disease. At doses of 100-150 mg daily, serious side effects will limit its use.

Functional, cognitive and behavioral effects of donepezil in patients with moderate Alzheimer's disease

OBJECTIVE

To investigate the efficacy and safety of donepezil in a subgroup of patients with Alzheimer's disease (AD) of moderate severity from a previous trial.

METHODS

Two hundred and seven patients with moderate AD (standardized Mini-Mental State Examination [sMMSE] score 10-17) were randomized to treatment in this 24-week, double-blind, placebo-controlled trial. Patents received either donepezil, 5 mg/day for the first 28 days and 10 mg/day thereafter according to the clinician's judgement (n = 102), or placebo (n = 105). The primary outcome measure was the Clinician's Interview-Based Impression of Change with caregiver input (CIBIC-plus) at week 24 using a last observation carried forward (LOCF) analysis.

RESULTS

Baseline patient demographics were similar between treatment groups. Mean age was 74.3 years (range 48-92). Least-squares (LS) mean sMMSE scores at baseline were 13.6 +/- 0.3 for the donepezil group and 13.9 +/- 0.3 for the placebo group. LS mean CIBIC-plus scores for donepezil-treated patients were improved from, or close to, baseline severity at all visits, and were significantly different from placebo at weeks 8, 12, 18, and 24 (week 24 LOCF mean difference = 0.53, p = 0.0003). LS mean change from baseline scores on the sMMSE and Severe Impairment Battery (SIB) for the donepezil group improved throughout the study, and were significantly different from placebo at each visit for the sMMSE (week 24 LOCF mean difference = 2.06, p = 0.0002) and from week 8 for the SIB (week 24 LOCF mean difference = -4.44, p = 0.0026). LS mean change scores on the Disability Assessment for Dementia remained at or above baseline levels throughout the study for the donepezil group, while the placebo group showed a steady decline; treatment differences were significant at each visit (week 24 LOCF mean difference = -9.25, p < 0.0001). LS mean change scores on the Neuropsychiatric Inventory 12-item total improved throughout the study for the donepezil group and were significantly different from placebo at weeks 4 and 24 (week 24 LOCF mean difference = 5.92, p = 0.0022). Eighty-one per cent of donepezil-treated and 89% of placebo-treated patients completed the trial, with 9% and 5%, respectively, discontinuing due to adverse events (AEs). Eighty-two per cent of donepezil-treated and 80% of placebo-treated patients experienced AEs, the majority of which were rated mild in severity and, in general, were similar between treatment groups.

CONCLUSION

The significant treatment responses observed with donepezil in these patients reinforce the findings from earlier studies that show donepezil to have important benefits, compared wih placebo, across functional, cognitive, and behavioral symptoms, with good tolerability, in patients with AD of moderate severity.

Serum p97 levels as an aid to identifying Alzheimer's disease

Background: The application of formal clinical diagnostic criteria for the identification of Alzheimer's Disease (AD) has improved diagnostic sensitivity. However, there remains a need for non-invasive biological markers and laboratory tests, which can facilitate case identification, and the assessment of treatment response. The p97 protein is a secreted protein specifically expressed by amyloid plaque associated reactive microglia that may have AD diagnostic ability. Methods: A quantitative radioimmunoassay was developed to measure serum p97. This study, under a double blind protocol, evaluated the utility of serum p97 as diagnostic test for AD. All subjects were referred to the UBC Clinic for Alzheimer's Disease and Related Disorders (CADRD) for clinical assessment of dementia. A serum p97 sample was obtained at the time of assessment but diagnosis of disease was determined independently of p97 examination. Results: "Possible" and "probable" AD cases (n = 41) and cognitively normal controls (n = 64) showed a highly significant difference in mean p97 concentration (41 vs. 20 ng/ml, p<0.001). There was some overlap in p97 distributions between AD cases and control subjects. The area under the curve (AUC) for the receiver operator curve (ROC) was 0.812. Conclusions: These results further support the specificity of high serum p97 levels in AD and its potential utility as a biological marker in AD. The reproducible elevation of serum p97 in AD underlines the need to further determine its role as a biological marker and diagnostic adjunct for AD.

Progression of impairment in patients with vascular cognitive impairment without dementia

Little is known about progression, short of dementia, in vascular cognitive impairment. In the Canadian Study of Health and Aging, 149 participants (79.3 +/- 6.7 years; 61% women) were found to have vascular cognitive impairment, no dementia (CIND). After 5 years, 77 participants (52%) had died and 58 (46%) had developed dementia. Women were at greater risk of dementia (OR 2.1, 1.0 to 4.5). Of 32 participants alive without dementia, cognition had deteriorated in seven and improved in four. Half of those with vascular CIND developed dementia within 5 years, suggesting a target for preventive interventions.

A 24-week, randomized, double-blind study of donepezil in moderate to severe Alzheimer's disease

OBJECTIVE

To investigate the efficacy and safety of donepezil in patients with moderate to severe AD (standardized Mini-Mental State Examination [sMMSE] scores of 5 to 17; Functional Assessment Staging score < or =6 at baseline).

METHODS

Two-hundred ninety patients were randomized to treatment in this 24-week, double-blind, placebo-controlled trial. Patients received either donepezil 5 mg/day for the first 28 days and 10 mg/day thereafter as per the clinician's judgment (n = 144) or placebo (n = 146). The primary outcome measure was the Clinician's Interview-Based Impression of Change with caregiver input (CIBIC+).

RESULTS

Patients' mean age was 73.6 years (range 48 to 92 years). Baseline demographics were similar between the treatment groups. Least squares (LS) mean +/- SE sMMSE scores at baseline were 11.7 +/- 0.35 for the donepezil group and 12.0 +/- 0.34 for the placebo group. Patients receiving donepezil showed benefits on the CIBIC+, compared with placebo, at all visits up to week 24 (p < 0.001) and at week 24 last observation carried forward (LOCF) (p < 0.0001). All other secondary measures (including sMMSE, Severe Impairment Battery, Disability Assessment for Dementia, Functional Rating Scale, and Neuropsychiatric Inventory) showed significant differences between the groups in favor of donepezil at week 24 LOCF. Eighty-four percent of donepezil- and 86% of placebo-treated patients completed the trial. Adverse events (AE) were experienced by 83% of donepezil- and 80% of placebo-treated patients, the majority of which were rated mild in severity; 8% of donepezil- and 6% of placebo-treated patients discontinued because of AE. Laboratory and vital sign abnormalities were similar between the treatment groups.

CONCLUSION

These data suggest that donepezil's benefits extend into more advanced stages of AD than those previously investigated, with very good tolerability.

The disability assessment for dementia scale: a 12-month study of functional ability in mild to moderate severity Alzheimer disease

The Disability Assessment for Dementia (DAD) scale was developed and validated as a measure of functional ability in dementia. DAD results have been reported in Alzheimer disease (AD) randomized, controlled treatment trials of up to 6 months, but results beyond 6 months have yet to be described. SAB INT 12 was a randomized, double-blind, placebo-controlled, parallel-group study in mild to moderate AD that included DAD assessments at baseline, month 6, and month 12. One hundred forty-four patients with AD in the placebo arm of SAB INT 12 were followed up for 12 months. DAD scores were obtained at baseline (mean DAD = 70.1, SD = 22.2), 6 months (mean DAD = 63.7, SD = 25.2), and 12 months (mean DAD = 59.3, SD = 28.9). The rate of decline was consistent across the domains of basic activities of daily living (ADLs) and instrumental ADLs, as well as the scoring of initiation, planning, and organization. The decline in DAD total scores in mild to moderate AD averages about one point per month, which equates to the loss of one item on the DAD scale every 2 months.

Effect of ethnicity on denial of authorization for emergency department care by managed care gatekeepers

OBJECTIVE

After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital.

METHODS

A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO.

RESULTS

African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94).

CONCLUSIONS

African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.

The recognition, assessment and management of dementing disorders: conclusions from the Canadian Consensus Conference on Dementia

OBJECTIVE

i) To develop evidence based consensus statements on which to build clinical practice guidelines for primary care physicians towards the recognition, assessment and management of dementing disorders; ii) to disseminate and evaluate the impact of these statements and guidelines built on these statements.

OPTIONS

Structured approach to assessment, including recommended laboratory tests, choices for neuroimaging and referral; management of complications (especially behaviour problems and depression) and use of cognitive enhancing agents. POTENTIAL OUTCOMES: Consistent and improved clinical care of persons with dementia; cost containment by more selective use of laboratory investigations, neuroimaging and referrals; appropriate use of cognitive enhancing agents.

EVIDENCE

Authors of each background paper were entrusted to: perform a literature search, discover additional relevant material including references cited in retrieved articles; consult with other experts in the field and then synthesize information. Standard rules of evidence were applied. Based upon this evidence, consensus statements were developed by a group of experts, guided by a steering committee of eight individuals from the areas of Neurology, Geriatric Medicine, Psychiatry, Family Medicine, Preventive Health Care and Health Care Systems.

VALUES

Recommendations have been developed with particular attention to the context of primary care and are intended to support family physicians in their ongoing assessment and care of patients with dementia.

BENEFITS, HARMS AND COSTS

Potential for improved clinical care of individuals with dementia. A dissemination and evaluation strategy will attempt to measure the impact of the recommendations.

RECOMMENDATIONS

See text.

VALIDATION

Four other sets of consensus statements and/or guidelines have been published recently. These recommendations are generally congruent with our own consensus statements. The consensus statements have been endorsed by relevant bodies in Canada.

Diagnosis, classification and natural history of degenerative dementias

The release of the first approved medications for the treatment of Alzheimer's disease in Canada has highlighted the renewed need and importance of diagnostic accuracy and understanding of the spectrum of the dementias. The epidemiological scope of the problem of dementia in Canada including risk factors, caregiving patterns and costs of care have been well-characterized through the Canadian Study of Health and Aging (CSHA 1991-1996) with some of the key findings reviewed here. Beyond Alzheimer's disease the phenotypes and genotypes of the other degenerative dementias have been emerging with proposed operational diagnostic criteria that should facilitate their recognition in clinical practice. This paper reviews the clinical phenotypes of the most common causes of dementia with a proposed classification scheme and with discussion of their relevance from a differential treatment standpoint. This paper served as a background document for the working group of the Consensus Conference on Dementia (C3D) in February 1998 and has been revised subsequently for this publication.

Age and sex differences in presentation of symptoms among patients with acute coronary disease: the REACT Trial. Rapid Early Action for Coronary Treatment

BACKGROUND

There are few data on possible age and sex differences in presentation of symptoms for patients with acute coronary disease.

OBJECTIVE

To investigate demographic differences in presentation of symptoms at the time of hospital presentation for acute myocardial infarction (AMI) and unstable angina.

METHODS

The medical records of patients who presented with chest pain and who also had diagnoses of AMI (n = 889) or unstable angina (n = 893) on discharge from 43 hospitals were reviewed as part of data collection activities of the Rapid Early Action for Coronary Treatment trial based in 10 pair-matched communities throughout the USA.

RESULTS

Dyspnea (49%), arm pain (46%), sweating (35%), and nausea (33%) were commonly reported by men and women of all ages in addition to the presenting complaint of chest pain. After we had controlled for various characteristics through regression modeling, older persons with AMI were significantly less likely than were younger persons to complain of arm pain and sweating, and men were significantly less likely to report vomiting than were women. Among persons with unstable angina, arm pain and sweating were reported significantly less often by elderly patients. Nausea and back, neck, and jaw pain were more common complaints of women.

CONCLUSIONS

Results of this study suggest that there are differences between symptoms at presentation of men and women, and those in various age groups, hospitalized with acute coronary disease. Clinicians should be aware of these differences when diagnosing and managing patients suspected to have coronary heart disease.

The diagnosis of "mixed" dementia in the Consortium for the Investigation of Vascular Impairment of Cognition (CIVIC)

If vascular risk factors are risk for Alzheimer's disease (AD), and if "pure" vascular dementia (VaD) is less common than has been thought, what do we make of the diagnosis of mixed dementia? We report characteristics of those with mixed dementia in a prospective, seven center, clinic-based Canadian study. Of 1,008 patients, 372 were diagnosed with AD, 149 with vascular cognitive impairment (VCI) including 76 with mixed AD/VaD, and 82 with other types of dementia. The mean age of patients with mixed AD/VaD was 78.0 +/- 7.6 years; 49% were female. These proportions differed significantly between dementia diagnosis subgroup (p < 0.001) showing a trend which is evident in all comparisons--AD/VaD patients fall in between AD and VaD. Vascular risk factors were present significantly more often in mixed AD/VaD than in AD (p < 0.001). More mixed AD/VaD (20%) than AD patients (4%) had focal signs, compared with 38% of those with vascular dementia and 12% with other types of dementia. Between the initial clinical diagnosis and the final diagnosis (which utilized neuroimaging and neuropsychological data) AD/VaD was the least stable diagnosis. Neuroimaging of ischemic lesions was the most common reason for reassignment from AD to the mixed AD/VaD diagnosis (17 cases). These data suggest that an operational definition of mixed AD/VaD can be proposed on presentation and clinical/radiographic findings, but indifferent to vascular risk factors. The concept of mixed dementia should be extended to include vascular dementia in combination with dementias, other than Alzheimer's disease.

Online measures of basic language skills in children with early focal brain lesions

Twenty children with early focal lesions were compared with 150 age-matched control subjects on 11 online measures of the basic skills underlying language processing, a digit span task, and 6 standardized measures. Although most of the children with brain injury scored within the normal range on the majority of the tasks, they also had a disproportionately high number of outlier scores on the reaction time tests. This evidence for a moderate impairment of the basic skills underlying language processing contrasts with other evidence suggesting that these children acquire normal control of the functional use of language. Furthermore, these children scored within the normal range on a measure of general cognitive ability, suggesting that there is no particular sparing of linguistic functions at the expense of general cognitive functions. Using the MPD procedure (Valdés-Pérez & Pericliev, 1997), we found that the controls and the five clinical groups could be best distinguished with two measures of online processing (word repetition and visual number naming) and one standardized test subcomponent (the CELF Oral Directions subtest). The 12 children with left hemisphere lesions scored significantly lower than the 8 other children on the CELF-RS measure. Within the group of children with cerebral infarct, the nature of the processing disability could be linked fairly well to site of lesion. Otherwise, there was little relation between site or size of lesion and the pattern of deficit. These results support a model in which damage to the complex functional circuits subserving language leads to only minor deficits in process efficiency, because of the plasticity of developmental processes.

Causes of Alzheimer's disease

It is now understood that genetic factors play a crucial role in the risk of developing Alzheimer's disease (AD). Rare mutations in at least 3 genes are responsible for early-onset familial AD. A common polymorphism in the apolipoprotein E gene is the major determinant of risk in families with late-onset AD, as well as in the general population. Advanced age, however, remains the major established risk factor for AD, although environmental variables may also have some role in disease expression. Some pathogenic factors directly associated with aging include oxidative damage and mutations in messenger RNA. Other factors unrelated to the aging process may, in the future, be amenable to therapeutic intervention by way of estrogen replacement therapy for postmenopausal women, anti-inflammatory drug therapy and reducing vascular risk factors. Older theories, such as aluminum playing a role in the pathogenesis of AD, have been mostly discarded as our understanding of pathogenic mechanisms of AD has advanced.

Outcome measures for the study of activities of daily living in vascular dementia

Decline in functional abilities is a major component of the dementia syndrome. The definition of dementia in the International Classification of Diseases (10th rev.) requires a cognitive impairment sufficient to impair personal activities of daily living (ADL). The Diagnostic and Statistical Manual of Mental Disorders (4th ed.) also requires cognitive deficits sufficiently severe to cause impairment in occupational or social functioning and must represent a decline from a higher level of functioning. However, the term disability is more appropriate than impairment to describe a loss in activities, as opposed to a loss of elementary functions, and is consistent with World Health Organization definitions of impairment, disability, and handicap. There is no doubt that ADL outcomes are required in therapeutic drug studies on vascular dementia, and there is a good rationale and some evidence for the use of ADL scales developed for therapeutic research in Alzheimer disease, favoring scales devoid of items sensitive to physical disabilities. Similarly, ADL-related clinical milestones could be used for longer-term studies aiming predominantly at slowing progression of disease in both early and later stages of dementia. Slower decline in ADL and delay in reaching ADL-related clinical milestones should be considered as valid outcomes by regulatory bodies in the process of dementia drug approval.

Seizure control and mortality in epilepsy

Mortality rates are increased among people with epilepsy, and may be highest in those with uncontrolled seizures. Because epilepsy surgery eliminates seizures in some people, we used an epilepsy surgery population to examine how seizure control influences mortality. We tested the hypothesis that patients with complete seizure relief after surgery would have a lower mortality rate than those who had persistent seizures. Three hundred ninety-three patients who had epilepsy surgery between January 1986 and January 1996 were followed after surgery to assess long-term survival; 347 had focal resection or transection, and 46 had anterior or complete corpus callosotomy. A multivariate survival analysis was performed, contrasting survival in those who had seizure recurrence with survival of those who remained seizure free. Standardized mortality ratios and 95% confidence intervals were calculated. Overall, seizure-free patients had a lower mortality rate than those with persistent seizures. This was true for the subset of patients with localized resection or multiple subpial transection. No patients died among 199 with no seizure recurrence, whereas of 194 patients with seizure recurrence, 11 died. Six of the deaths were sudden and unexplained. Most patients who died had a substantial reduction in postoperative seizure frequency. The standardized mortality ratio for patients with recurrent seizures was 4.69, and the risk of death in these patients was 1.37 in 100 person-years, whereas among patients who became seizure free, there was no difference in mortality rate compared with the age- and sex-matched population of the United States. Elimination of seizures after surgery reduces mortality rates in people with epilepsy to a level indistinguishable from that of the general population, whereas patients with recurrent seizures continue to suffer from high mortality rates. This suggests that uncontrolled seizures are a major risk factor for excess mortality in epilepsy. Achieving complete seizure control with epilepsy surgery in refractory patients reduces the risk of death, so the long-term risk of continuing medical treatment appears to be higher than the risk of epilepsy surgery in suitable candidates.