The assessment of frailty in older adults

No clear consensual definition regarding frailty seems to emerge from the literature after 30 years of research in the topic, and a large array of models and criteria has been proposed to define the syndrome. Controversy continues to exist on the choice of the components to be included in the frailty definition. Two main definitions based on clusters of components are found in literature: a physical phenotype of frailty, operationalized in 2001 by providing a list of 5 measurable items of functional impairments, which coexists with a multidomain phenotype, based on a frailty index constructed on the accumulation of identified deficits based on comprehensive geriatric assessment. The physical phenotype considers disability and comorbidities such as dementia as distinct entities and therefore outcomes of the frailty syndrome, whereas comorbidity and disability can be components of the multidomain phenotype. Expanded models of physical frailty (models that included clusters other than the original 5 items such as dementia) increased considerably the predicting capacity of poor clinical outcomes when compared with the predictive capacity of the physical phenotype. The unresolved controversy of the components shapes the clusters of original frailty syndrome, and the components depend very much on how frailty is defined. This update also highlights the growing evidence on gait speed to be considered as a single-item frailty screening tool. The evaluation of gait speed over a short distance emerges from the literature as a tool with the capacity to identify frail older adults, and slow gait speed has been proven to be a strong predictor for frailty-adverse outcomes.

Effectiveness of a specific care plan in patients with Alzheimer's disease: cluster randomised trial (PLASA study)

OBJECTIVE

To test the effectiveness of a comprehensive specific care plan in decreasing the rate of functional decline in patients with mild to moderate Alzheimer's disease compared with usual care in memory clinics.

DESIGN

Cluster randomised trial.

SETTING

50 memory clinics in France.

PARTICIPANTS

Patients with Alzheimer's disease (mini-mental state examination score 12-26). 1131 patients were included: 574 from 26 clinics in the intervention group, and 557 from 24 clinics in the usual care (control) group. Memory clinics were the unit of randomisation.

INTERVENTION

The intervention included a comprehensive standardised twice yearly consultation for patients and their caregivers, with standardised guidelines for the management of problems identified during the assessment.

MAIN OUTCOME MEASURES

The primary outcome measure was change on the Alzheimer's Disease Cooperative Study-activities of daily living scale assessed at 12 and 24 months. Secondary outcome measures were the rate of admission to institutional care and mortality.

RESULTS

At two years the assessment was completed by 58.4% (n=335) of patients in the intervention group and 61.6% (n=343) in the control group. The rate of functional decline at two years did not differ between the groups. The annual rate of change on the Alzheimer's Disease Cooperative Study-activities of daily living was estimated at -5.73 (95% confidence interval -6.89 to -4.57) in the intervention group and -5.96 (-7.05 to -4.86) in the control group (P=0.78).

CONCLUSION

A comprehensive specific care plan in memory clinics had no additional positive effect on functional decline in patients with mild to moderate Alzheimer's disease. Future research should aim to determine the effects of more direct involvement of general practitioners.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00480220.

PUFA for prevention and treatment of dementia?

Polyunsaturated fatty acids (PUFA) play a crucial role in cerebral structure and function. Omega-3 PUFA is an exciting area of research, with docosahexaenoic acid (DHA) emerging as a new potential agent for prevention of cognitive decline and treatment of Alzheimer's disease. Preclinical studies suggest that DHA maintains membrane fluidity, improves synaptic and neurotransmitter functioning, enhances learning and memory performances and displays neuroprotective properties. Several epidemiological studies supported the association between Omega-3 PUFA consumption and a lower prevalence of dementia. Although data are divergent, a growing body of evidence supports the view that regular consumption of dietary fish and seafood (which are rich in omega-3 PUFA) prevents cognitive decline. Finally, at present, few data are available from randomized clinical trials (RCTs). on the association between cognition and Omega-3. Ongoing RCTs that assess the effect of Omega-3 might provide new evidence on prevention and treatment of dementia. In this review, we summarize preclinical and clinical research suggesting that DHA exerts beneficial effects on cognitive function with ageing.

Spared and impaired abilities in community-dwelling patients entering the severe stage of Alzheimer's disease

BACKGROUND

Comprehensive geriatric assessments of patients entering the severe stage of Alzheimer's disease (AD) are scarce.

METHODS

Cross-sectional study of 126 patients entering the severe stage of AD in the longitudinal study of REAL.FR cohort. Patients who had a first MMSE score <10 during follow-up underwent cognitive, behavioral, nutritional and functional assessment. Support requirements were also evaluated.

RESULTS

The best-preserved cognitive abilities were social interaction and response to own name, while praxis, orientation, memory and language showed the largest declines. Regarding independence in daily living, locomotion was best preserved (71% of patients independent) while personal hygiene deteriorated most (15.5%). Behavioral disorders were frequent, and consisted principally of apathy, aberrant motor behavior, and agitation. The Mini Nutritional Assessment showed that 68.5% of patients were malnourished or at risk of malnutrition. Caregiver burden remained mild to moderate in 69.8% of cases. In addition, 80% of patients still lived at home and 71.6% used at least 2 support services, consisting mainly of physician visits and home help.

CONCLUSION

Assessment of remaining cognitive, functional abilities and behavioral disorders at entry to severe AD should help to improve targeted management aimed at preserving these abilities and treating complications, thereby optimizing these patients' quality of life.

Alzheimer's disease progression in the oldest old compared to younger elderly patient: data from the REAL.FR study

OBJECTIVE

Although population-based studies have revealed marked increases in the prevalence and incidence of dementia, particularly in older age groups, longitudinal studies of cognitive change have been less frequently conducted. The aim of this study is to describe the progression of Alzheimer's disease (AD) in the oldest old (>or=85 years) and to compare it with the younger elderly.

METHODS

A cohort of 114 AD patients >or=85 years old and 572 AD patients <85 years living in the community at inclusion were monitored over 2 years in 16 centers of the French AD network (REAL.FR study). Each subject underwent extensive medical examination including functional (Activities of Daily Living or ADL) and neuropsychological evaluations (including Mini Mental Status Evaluation or MMSE) every 6 months.

RESULTS

The observed decrease in MMSE performance in patients >or=85 was -4.18 +/- 0.63 points during the 2-year follow-up (vs -4.62 +/- 0.25 in the younger group) with no statistically significant differences between the two groups. After adjusting for confounding factors, ADL score declined faster in the oldest old than in individuals <85 years old during the 2-year follow-up: -1.73 +/- 0.19 vs -1.27 +/- 0.08 (p = 0.0309).

CONCLUSIONS

Our study showed, that while the progression of cognitive impairment was identical in both groups, after adjustment for variables related both to age and dependency, the progression of dependency was more rapid in those over 85 years old.

Predictive value of rapid decline in mini mental state examination in clinical practice for prognosis in Alzheimer's disease

BACKGROUND

Given the poorer prognosis of Alzheimer's disease (AD) patients with rapid cognitive decline (RCD), there is a need for a clinical assessment tool to detect these patients.

OBJECTIVE

To investigate if there is a Mini Mental State Examination (MMSE) threshold of decline during 6 months of follow-up which predicts a worse disease progression at the 2-year follow-up. Then, to propose a feasible definition of RCD for routine clinical practice.

METHODS

Data from 565 community-dwelling AD patients recruited in a multi-centre prospective observational study were assessed. All patients had MMSE scores between 10 and 26 at inclusion and were followed up 6-monthly using a standardised clinical assessment. Patients were classified as rapid and non-rapid decliners according to 2 MMSE decline thresholds tested: >or=3 points and >or=4 points for decline over the first 6 months of the study. Worse disease outcome was defined as attainment of 1 of 4 clinical end points 18 months later: institutionalisation, death, increased physical dependence or worsening of behavioural and psychological symptoms.

RESULTS

135 patients (23.9%) lost >or=3 points during the first 6 months of follow-up in the MMSE score and 77 patients (13.6%) lost >or=4 points. Patients with moderate disease and a loss of >or=4 points showed a significantly increased risk of mortality (HR = 5.6, 95% CI 2.0-15.9) and institutionalisation (HR = 3.8, 95% CI 1.8-8.1) at the 2-year follow-up. The same MMSE threshold was associated with a higher risk of physical decline (HR = 1.6, 95% CI 1.2-2.3).

CONCLUSION

The loss of >or=4 points in MMSE during the first 6 months of follow-up seems to be a predictor of worse clinical course, and thus it could be used to define the category of AD patients presenting a RCD.

Rapid cognitive decline in Alzheimer's disease. Consensus paper

The rate of cognitive decline in Alzheimer's disease (AD) varies considerably between individuals, with some subjects showing substantial deterioration and others showing little or no change over the course of the disease. These wide variations support the relatively new concept of Rapid Cognitive Decline (RCD). Patients with an accelerated rate of cognitive decline have showed to present a worse evolution in terms of mortality, loss of autonomy and institutionalisation. The conclusions from RCD studies conducted in the past years remain very heterogeneous and sometimes contradictory. This is possibly due to methodological differences, mainly the different "a priori" definitions of RCD used to identify rapid decliners. Consequently of this, there is considerable variation in reported frequency of patients with RCD which may vary from 9.5% to 54%. The lack of both consensus definition and consensual clinical assessment tools is one of the major barriers for establishing an appropriated management of rapid decliners in clinical practice. Presently, management of rapid decliners in AD remains to be a challenge waiting to better know predictive factors of a RCD. To date no specific guidelines exist to follow-up or to treat patients with this condition. This consensus paper proposes the loss of 3 points or greater in Mini-Mental State Examination (MMSE) during six months as an empirical definition of rapid cognitive decline to be used in routine medical practice and to be relevant for clinical-decision making in patients with mild to moderately-severe AD.

Caloric restriction and brain function

PURPOSE OF REVIEW

In addition to extending lifespan, animal research shows that specific diets benefit brain functioning. Indeed, it has been proven that caloric restriction prevents age-related neuronal damage. What are those mechanisms involved in the effects of caloric restriction on brain functioning? Could caloric restriction be proposed in the future to prevent or treat neurodegenerative disorders such as Alzheimer's disease? Is there a future for caloric restriction interventions in adults?

RECENT FINDINGS

Hypotheses linking caloric restriction to cognitive capability include anti-inflammatory mechanisms, reduction of neural oxidative stress, promotion of synaptic plasticity, induction of various stress and neurotrophic/neuroprotective factors. Caloric restriction may also prevent beta-amyloid neuropathology in Alzheimer transgenic models. Finally, both exercise and caloric restriction enhance neurogenesis via different mechanisms suggesting that their combination may decrease the risk of neurodegenerative disease.

SUMMARY

It is now well established that caloric restriction could be used to promote successful brain aging. Data from randomized controlled trials in humans are limited. No positive effect on cognitive impairment was found probably due to methodological limitations. The long-term effects of caloric restriction in adults must be clarified before engaging in such preventive strategy. Additional animal studies must be conducted in the future to test the effects of 'multidomain' interventions (caloric restriction plus regular exercise) on age-related cognitive decline.

Prognosis of Alzheimer's disease today: a two-year prospective study in 686 patients from the REAL-FR Study

BACKGROUND

The aim of the present study was to describe the long-term evolution of Alzheimer's disease (AD) in a prospective cohort of patients under treatment with a close follow-up.

METHODS

Six hundred eighty-six AD patients from the French Network on AD (REAL-FR) were followed up and assessed every 6 months for 2 years. Cognitive, functional, behavioral, nutritional, and global status were evaluated by using Mini-Mental State Examination (MMSE), cognitive subscale of AD Assessment Scale (ADAS-cog), Activities of Daily Living scale (ADL), Neuropsychiatric Inventory (NPI), Mini-Nutritional Assessment (MNA), and Clinical Dementia Rating (CDR).

RESULTS

There were 85.13% of patients who were specifically treated for AD during their participation in the study. We observed significant changes (P < .0001) on MMSE, -4.57 +/- 0.23; ADAS-cog, 7.11 +/- 0.41; ADL, -1.32 +/- 0.07; NPI, 2.94 +/- 0.77; MNA, -0.81 +/- 0.17; and sum of boxes of the CDR (CDR-SB), 4.17 +/- 0.17. After 2 years, 10.79% (95% confidence interval [CI], 8.47 to 13.11) of the patients evolved twice as rapidly as the mean of the whole cohort on MMSE (loss, > or =9 points), 65.89% (95% CI, 62.34 to 69.44) reported a loss of 3 to 9 points, and 23.32% (95% CI, 20.16 to 26.46) were stable or improved (loss of -2 points maximum). Annual incidences for institutionalization, hospitalization, and death were 11.84% (95% CI, 9.76 to 13.92), 26.13% (95% CI, 22.52 to 29.74), and 5.95% (95% CI, 4.56 to 7.34), respectively.

CONCLUSIONS

In a recent large AD cohort mostly under treatment, AD evolution appeared to be variable, with high incidences for death or institutionalization and with 11.84% of the patients exhibiting a rapid cognitive decline, whereas one fourth of the cohort appeared in relatively stable condition, and two thirds had a moderate but significant evolution of the disease. More studies are needed to better understand these variations in patients' evolution.

Predictive factors of attrition in a cohort of Alzheimer disease patients. The REAL.FR study

BACKGROUND

Attrition, i.e. patient dropout, can threaten the validity of results in longitudinal studies. The aim of this study was to identify patient and caregiver factors predictive of attrition in a cohort of Alzheimer disease (AD) patients.

METHODS

686 patients with mild to moderate AD were included in the multicenter prospective REAL.FR study. Standardized gerontological evaluations were carried out twice yearly. Factors associated with attrition were assessed by survival analysis using a Cox proportional hazard model.

RESULTS

After 2 years, 278 (40.5%) patients had dropped out. Causes of attrition included refusal (20.9%), death (20.1%), institutionalization (19.8%), and loss to follow-up (19.8%). Attrition rates between each 6-month wave were constant at 12%. After adjustment, several independent factors remained associated with attrition: patients cared for by an unrelated caregiver [HR 1.7; 95% CI (1.08-2.59)], loss of autonomy [HR = 1.37; (1.03-1.82)], increasing caregiver burden [HR = 1.014; (1.005-1.022)], use of cholinesterase inhibitors [HR = 0.40; (0.27-0.59)], use of 1 to 3 other types of medication [HR = 0.57; (0.36-0.89)].

CONCLUSIONS

The identification of both patient and caregiver factors predictive of attrition is of particular interest for the development and targeting of attrition prevention strategies. In patients with chronic diseases, particular attention should be paid to caregiver well-being to limit attrition.

A 2-year follow-up of 233 very mild (CDR 0.5) Alzheimer's disease patients (REAL.FR cohort)

OBJECTIVES

Making an early diagnosis of Alzheimer's Disease (AD) is becoming increasingly important. The Clinical Dementia Rating scale (CDR), a semi-structured interview with patient and caregiver, is a global rating scale designed for use in staging dementia. The primary objective of our study was to examine the evolution of AD in individuals with very mild AD (CDR 0.5) across a 2-year follow up.

METHODS

A cohort of AD patients (n=682) living in the community were followed during 2 years in 16 centres of the French AD network. Each subject underwent extensive medical examination including the MMSE and CDR every 6 months.

RESULTS

Two hundred and thirty-three AD patients were rated CDR 0.5 at baseline (mean MMSE score: 23.15+/-2.57). They were younger and reported an average duration of symptoms of approximately 0.8 years less than patients with CDR >or= 1.During the 2-year follow-up, none of the AD CDR 0.5 subjects improved; 65% of them showed an increase in the CDR score. The rate of cognitive decline was similar between the AD CDR 0.5 and CDR >or= 1 groups. The ADL decline was more significant in patients with CDR >or= 1 at inclusion.

CONCLUSIONS

It is certainly possible to identify AD at a very early stage focusing on intra individual change in cognitive and functional impairment. Criteria with a high sensitivity and specificity for detecting AD at an early stage will help to further develop effective pharmacological and behavioural interventions for delaying the onset and progression of the disease.

Apathy and depression in Alzheimer's disease are associated with functional deficit and psychotropic prescription

BACKGROUND

Apathy and depression are the most common neuropsychiatric features in Alzheimer's disease (AD). The clinical and functional specific correlates of these syndromes are not well known independently from cognitive deficits and other behavioral disturbances.

MATERIAL AND METHODS

Six hundred and eighty-six patients diagnosed with possible or probable AD were included in a prospective multicenter study (REAL-FR). They had an assessment of their cognitive and functional status. Neuropsychiatric symptoms were assessed with the Neuropsychiatric Inventory (NPI) and caregiver's burden was measured with Zarit's Burden Scale.

RESULTS

A majority of patients at any stage of the disease presented with one or several behavioral and psychological disturbances. Apathy concerned 43% of patients and, with or without depression, was associated with more pronounced deficits in global cognition, everyday life and instrumental abilities, nutritional status and with a higher burden level. A high level of psychotropic prescription, especially with antidepressant, was observed in patients with apathy. In a multivariate analysis taking into account the cognitive and functional variables of AD, apathy and depression were the only significant predictors of psychotropic prescription.

CONCLUSION

Some negative neuropsychiatric symptoms such as apathy and depression have a specific relation with functional and therapeutic outcomes of AD, independently from cognitive status. Further studies are needed to establish if apathy represents a particularly severe phenotype of AD.

A randomized trial of the impact of a specific care plan in 1120 Alzheimer's patients (PLASA Study) over a two-year period: design and baseline data

OBJECTIVE

To describe the design anf baseline patient characteristics of a multicomponent specific care and assistance plan (PLASA) study in Alzheimer's Disease (AD). The study is designed to evaluate the effect of PLASA in AD primarily looking at change in functional capacity.

DESIGN

Two-years prospective cluster randomized controlled trial comparing PLASA and usual care.

SETTING

Forty-nine hospitals in France.

PARTICIPANTS

1120 community-dwelling AD.

INTERVENTION

Patients in the intervention group are evaluated biannually using a standardized comprehensive global assessment. In the case of decline in any one domain a standardized study protocol recommends specific physician directed intervention in addition to information and training for the caregiver.

MEASUREMENTS

Alzheimer Disease Cooperative Study-Activities of Daily Living scale, Resource Utilization in Dementia scale, Clinical Global Impression of Change.

RESULTS

At baseline, the two groups were similar regarding patient and caregiver characteristics. The mean patient age was 79.61+5.72 years and the mean MMSE 19.73+4.01 for the whole cohort. Time since dementia diagnosis was about 1.37+1.65 years in the whole cohort. Almost a third of the patients lived alone at baseline. Mean monthly time spent in caregiving in the whole cohort was 52.70+71.83 hours for instrumental activities and 17.73+51.38 hours for basic activities.

CONCLUSION

Persons with dementia suffer different losses at different stages of the disease and therefore accurate assessment of abilities and losses is critical to assist the person in planning for their future and for care needs. The PLASA intervention study is ongoing with 2 year follow-up to be completed in 2007.

Outcome of Alzheimer's disease: potential impact of cholinesterase inhibitors

BACKGROUND

Alzheimer's disease is fast becoming a major public health concern with serious economic consequences. The cholinesterase inhibitors (CEIs) offer some benefit in the symptomatic treatment of the disease. This study aims to investigate the effect of CEIs on three clinically relevant domains (rapid cognitive decline, institutionalization, and weight loss) in patients with Alzheimer's disease.

METHODS

A prospective observational study was performed in which a population of 455 Alzheimer's disease patients were recruited and followed up for at least 1 year between 1994 and 2002. Patients were reevaluated at 6 monthly intervals using standardized neurocognitive and geriatric evaluations in addition to complete clinical examination, standard paraclinical investigations, and recording of treatment received.

RESULTS

The risk of rapid cognitive deterioration was significantly decreased in patients taking CEIs for at least 1 year compared to untreated patients (odds ratio [OR]=0.56, 95% confidence interval [CI], 0.34-0.93; p=.025). The potential benefit of CEI use was also found on institutionalization (OR=0.2, 95% CI, 0.08-0.48; p<.001) and weight loss (OR=0.56, 95% CI, 0.32-0.97; p=.039) after 1 year of follow-up.

CONCLUSION

The special interest of this study is that all patients were recruited and followed in the same center with the same management care plan and the same medical team. This follow-up offers us a unique opportunity to compare the 1-year evolution of the disease in clinical practice before and after the marketing of CEIs and allows us to demonstrate a clinically significant improvement in patient outcome over time.

Family history of dementia does not influence the progression of Alzheimer's disease at two years: results from the REAL.FR Study

The purpose of this study was to determine whether a family history of dementia in a first-degree relative influenced the progression of Alzheimer's disease (AD) after two years of follow-up. Patients were recruited in the REAL.FR (Réseau sur la Maladie d'Alzheimer Français) study and underwent behavioral, global, nutritional, and medical evaluation with assessment of cognitive function and independence every six months. At inclusion, 113 patients reported a family history of dementia, and 358 patients had no family history of dementia. There was no statistical difference for any factors between the two groups at baseline. After two years of follow-up, a similar percentage of patients were still followed in each group, and although most parameters showed significant deterioration, there was no difference between the two groups, indicating that a family history of dementia does not appear to influence the progression of AD.

Cognitive impairment and composition of drinking water in women: findings of the EPIDOS Study

BACKGROUND

The concentration of aluminum or silica in drinking water may be a potential environmental risk factor for Alzheimer disease (AD).

OBJECTIVES

The objective was to investigate at baseline the potential association between the composition of drinking water and the level of cognitive function in women taking part in the Epidemiology of Osteoporosis (EPIDOS) Study and to determine during follow-up the effects of the composition of drinking water on the risk of AD.

DESIGN

Women aged >/=75 y (n = 7598) were recruited between 1992 and 1994 in 5 geographic areas of France. The participants from one center (n = 1462) were followed for </=7 y; during this time, an active search for incident cases of AD was conducted. The initial questionnaire comprised a food consumption survey with specific questions about the daily consumption of tap and mineral water. The evaluation of cognitive function was based on the Short Portable Mental Status Questionnaire. During follow-up, the diagnosis of dementia was made by a geriatrician and a neurologist.

RESULTS

A low silica concentration was associated with low cognitive performance at baseline. Compared with the nondemented subjects, the women with a diagnosis of AD during follow-up were older at inclusion, had a lower financial status and educational level, had a poorer perception of their own health, and had a more difficult time performing activities of daily living. A multivariate analysis including potential confounding factors showed that women with AD appeared to have been exposed to lower amounts of silica at baseline.

CONCLUSIONS

Silica in drinking water may reduce the risk of developing AD in elderly women. The results corroborate those of another epidemiologic study carried out in France. The potential effect of silica needs to be confirmed in additional investigations.