The Test for Severe Impairment: an instrument for the assessment of patients with severe cognitive dysfunction

Dementia in an Irish population of Down's syndrome people

Objective: To determine the prevalence of dementia in an Irish sample of Down's syndrome (DS) patients and to examine the utility of a number of cognitive and functional scales in the assessment of dementia in this population.

Method: 76 DS patients diagnosed clinically (range 33–72 years; mean age 47.3 ± 8.8 years) were included in the study. The diagnosis of dementia was made on clinical grounds using DSMIIIR criteria. Cognitive and functional impairment were evaluated using the following scales; Test for Severe Impairment (TSI), Down's Syndrome Mental Status Examination (DSMSE), Daily Living Skills Questionnaire (DLSQ), and the Mental State Performance (MSP).

Results: The overall prevalence of dementia was 7.9% (95% C.I = 2.95–16.39). The presence of dementia was associated with late onset epilepsy, anticonvulsant medication and deafness. Standard cognitive tests such as the MSP showed an early ‘floor’ effect in this population. In contrast the TSI and DLSQ showed a satisfactory range of scores in these patients with moderate to severe learning disability.

Conclusions: The low prevalence of dementia in this study may be explained by the strict conservative criteria applied in the clinical diagnosis. Prospective assessment of DS patients on a longitudinal basis using decline on scales such as the TSI and DLSQ may allow more accurate diagnosis of dementia at an earlier stage in this at-risk population.

Cognitive and affective assessment in day care versus institutionalized elderly patients: a 1-year longitudinal study

Purpose

Cognitive decline and depression are two common mental health problems that may create a need for long-term care among the elderly. In the last decade, the percentage of older adults who receive health care in nursing homes, day care centers, or home support services has increased in Europe. The objectives of this descriptive and nonrandomized longitudinal study were to evaluate and to compare the cognitive and affective evolution of day care versus institutionalized older patients through a 1-year period, and to assess the presence of cognitive and affective impairment as a function of the care setting.

Patients and methods

Ninety-four patients were assessed at baseline, and 63 (67.0%) were reassessed 1 year later. Neuropsychological assessment included measures of cognitive performance (general cognitive status, visuospatial, and language abilities) and affective status (depressive symptoms).

Results

Our findings indicated that the majority of the participants (day care and institutionalized patients) had mild–moderate cognitive impairment at baseline, which significantly increased in both groups after 1-year follow-up. However, the rate of change in global cognitive function did not significantly differ between groups over time. Regarding language abilities, naming function maintained among day care patients in comparison with institutionalized patients, who showed worse performance at follow-up. As regards to affective status, results revealed that institutionalized patients had a significant reduction in depressive symptoms at follow-up, when compared to day care patients. Results also highlight the high frequency of cognitive impairment and depressive symptoms regardless of the care setting.

Conclusion

Our findings revealed a similar global cognitive decline rate between patients receiving day care services and those residing in a nursing home at the 1-year follow-up, and slightly different trajectories in other outcomes such as naming function and depressive symptoms.

What it's like to grow older: the aging perceptions of people with an intellectual disability in Ireland

The Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing is a national longitudinal study on the aging of people with an intellectual disability (ID) using a randomly selected sample of people with ID over the age of 40. In total, 367 people with an ID completed the aging perception self-report only section. Over 57% of people described their health as very good to excellent with no significant difference in health perceptions found for gender, level of ID, or living circumstance. Exploring people's perceptions utilizing PASW Text Analytics for Surveys 4.1 perceptions often supported negative views of the consequences of aging. These findings suggest challenging negative aging concepts is essential to promote positivity with associated improved health and wellbeing.

Expressed Sense of Self by People With Alzheimer’s Disease in a Support Group Interpreted in Terms of Agency and Communion

The self is constructed in cooperation with other people and social context influences how people perceive and express it. People with Alzheimer’s disease (AD) often receive insufficient support in constructing their preferred selves, but little is known about how they express themselves together with other people with AD. In accordance with Harré’s social constructionist theory of self, this study aimed to describe how five people with mild and moderate AD express their Self 2 (i.e., their personal attributes and life histories) in a support group with a facilitator experienced in communicating with people with AD. The participants’ expressions of their Self 2 were analyzed with qualitative abductive content analysis and interpreted in terms of agency and communion and a lack of agency and communion. The findings highlight the importance of supporting a sense of agency and communion when assisting people with AD in constructing their self.

Educational bias in the assessment of severe dementia: Brazilian cutoffs for severe Mini-Mental State Examination

Cognitive assessment in advanced stages of Alzheimer’s disease (AD) is limited by the imprecision of most instruments. Objective: To determine objective cognitive responses in moderate and severe AD patients by way of the Severe Mini-Mental State Examination (SMMSE), and to correlate performances with Mini-Mental State Examination (MMSE) scores. Method: Consecutive outpatients in moderate and severe stages of AD (Clinical Dementia Rating 2.0 or 3.0) were evaluated and compared according to MMSE and SMMSE scores. Results: Overall 400 patients were included, 67.5% females, mean age 76.6±6.7 years-old. There was no significant impact of age or gender over MMSE or SMMSE scores. Mean schooling was 4.4±2.5 years, impacting SMMSE scores (p=0.008). Scores on MMSE and SMMSE were significantly correlated (F-ratio=690.6325, p<0.0001). Conclusion: The SMMSE is influenced by schooling, but not by age or gender, and is an accurate test for assessment of moderate and severe AD.

Dementia and mild cognitive impairment in adults with intellectual disability: issues of diagnosis

Individuals with intellectual disability (ID) are now living longer with the majority of individuals reaching middle and even "old age." As a consequence of this extended longevity they are vulnerable to the same age-associated health problems as elderly adults in the general population without ID. This includes dementia, a general term referring to a variety of diseases and conditions causing substantial loss of cognitive ability and functional declines; adults with Down syndrome are at especially high risk. A great deal of recent effort has focused on the very earliest detectable indicators of decline (and even prodromal stages of dementia-causing diseases). A condition called mild cognitive impairment (MCI) has been conceptually defined as a decline in functioning that is more severe than expected with typical brain aging but not severe enough to meet criteria for a diagnosis of dementia. Consensus criteria for both dementia and MCI have been developed for typically developing adults but are of limited applicability for adults with ID, given their pre-existing cognitive impairments. Early diagnosis will continue to be of growing importance, both to support symptomatic treatment and to prevent irreversible neuropathology when interventions are developed to slow or halt the progression of underlying disease. While the intellectual and developmental disabilities field has for some time recognized the need to develop best-practices for the diagnosis of MCI and dementia, there remains a pressing need for empirically based assessment methods and classification criteria.

A prospective 14-year longitudinal follow-up of dementia in persons with Down syndrome

BACKGROUND

To examine dementia characteristics, age at onset and associated comorbidities in persons with Down syndrome.

METHOD

Seventy-seven people with Down syndrome aged 35 years and older were followed longitudinally. The diagnosis of dementia was established using the modified International Classification of Diseases, Tenth Revision (ICD-10) criteria and a combination of objective and informant-based tests. Cognitive tests included the Test for Severe Impairment and the Down Syndrome Mental Status Examination; adaptive behaviour was measured using the Daily Living Skills Questionnaire. The Dementia Questionnaire for Mental Retarded Persons (DMR) was added to the test battery in 2005 and this study includes follow-up data for this instrument.

RESULTS

Over the 14-year period the average age of diagnosis at 55.41 years (SD = 7.14) was in the higher range of previously reported estimates (51-56 years) and a median survival of 7 years after diagnosis. Persons with dementia in the sample were significantly older than persons without dementia. The presence of dementia was also associated with epilepsy and sensory impairments. Among instruments the DMR appeared most sensitive to tracking change in symptoms over time before diagnosis.

CONCLUSION

The previously reported high risk levels for dementia among people with Down syndrome was confirmed in these data as was the value of the instruments utilised in tracking decline and helping to confirm diagnosis even in persons with severe intellectual disability.

A systematic review on assessment instruments for dementia in persons with intellectual disabilities

AIM

This work describes an extensive systematic literature review on assessment instruments for dementia in persons with intellectual disability (ID). Existing instruments for the detection of dementia in persons with ID were collected and described systematically. This allows a direct and quick overview of available tools. Additionally, it contributes to the availability and usability of information about these instruments, thus enhancing further developments in this field.

METHODS

A systematic literature search in five databases (CINAHL, PsycInfo, PubMed, Scopus, and Web of Science) was conducted. In order to include gray literature an invisible college approach was used. Relevant studies were identified and selected using defined inclusion and exclusion criteria. After the selection process all instruments were coded and classified. It was determined which concepts they assess, whether they were especially developed or adapted for persons with ID, and whether they were designed to assess dementia. The selection of relevant papers, as well as the coding of instruments was done independently by two researchers.

RESULTS

In total, 97 records met the search criteria. Out of these, 114 different instruments were extracted. There were 79 instruments to be completed by the person with ID, and 35 informant-based instruments. Additionally, four test batteries were found. Some of these instruments were neither designed for the assessment of dementia, nor for persons with ID.

CONCLUSIONS

There are a variety of different tools used for the assessment of dementia in ID. Nevertheless, an agreed-upon approach or instrument is missing. Establishing this would improve the quality of assessment in clinical practice, and benefit research. Data collected would become comparable and combinable, and allow research to have more informative value.

The cost-effectiveness of the decision to hospitalize nursing home residents with advanced dementia

CONTEXT

Nursing home (NH) residents with advanced dementia commonly experience burdensome and costly hospitalizations that may not extend survival or improve quality of life. Cost-effectiveness analyses of decisions to hospitalize these residents have not been reported.

OBJECTIVES

To estimate the cost-effectiveness of 1) not having a do-not-hospitalize (DNH) order and 2) hospitalization for suspected pneumonia in NH residents with advanced dementia.

METHODS

NH residents from 22 NHs in the Boston area were followed in the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study conducted between February 2003 and February 2009. We conducted cost-effectiveness analyses of aggressive treatment strategies for advanced dementia residents living in NHs when they suffer from acute illness. Primary outcome measures included quality-adjusted life days (QALD) and quality-adjusted life years, Medicare expenditures, and incremental net benefits (INBs) over 15 months.

RESULTS

Compared with a less aggressive strategy of avoiding hospital transfer (i.e., having DNH orders), the strategy of hospitalization was associated with an incremental increase in Medicare expenditures of $5972 and an incremental gain in quality-adjusted survival of 3.7 QALD. Hospitalization for pneumonia was associated with an incremental increase in Medicare expenditures of $3697 and an incremental reduction in quality-adjusted survival of 9.7 QALD. At a willingness-to-pay level of $100,000/quality-adjusted life years, the INBs of the more aggressive treatment strategies were negative and, therefore, not cost effective (INB for not having a DNH order, -$4958 and INB for hospital transfer for pneumonia, -$6355).

CONCLUSION

Treatment strategies favoring hospitalization for NH residents with advanced dementia are not cost effective.

Foot massage versus quiet presence on agitation and mood in people with dementia: a randomised controlled trial

BACKGROUND

There is increasing interest in using complementary and alternative treatments to manage behavioural and psychological symptoms of dementia such as agitation, aggression and depressed mood.

OBJECTIVE

To compare the effect of foot massage (intervention) and quiet presence (control) on agitation and mood in people with dementia.

DESIGN

A randomised controlled trial using a within-subjects, crossover design.

SETTINGS

Five long-term care facilities in Brisbane, Australia. The primary outcome was the Cohen-Mansfield Agitation Inventory (CMAI) and the secondary outcome was the Observed Emotion Rating Scale (OERS). The screening and data collection research assistants, families, and care staff were blinded to participant allocation.

PARTICIPANTS

Participants of the study were 55 long-term care residents aged 74-103 years (mean age 86.5), with moderate to severe dementia and a history of agitated behaviour according to the Pittsburgh Agitation Scale. A computer-program randomised participants to 10-min foot massage (intervention) or quiet presence (control), every weekday for 3 weeks.

RESULTS

A carry-over effect was identified in the data, and so the data was treated as a parallel groups RCT. The mean total CMAI increased in both groups (reflecting an increase in agitation) with this increase greater in the quiet presence group than the foot massage group (p=0.03). There was a trend towards a difference on OERS General Alertness, with a positive change in alertness for participants in the foot massage group (indicating reduced alertness) and a negative change for participants in the quiet presence group (indicating increased alertness) (F(1,51)=3.88, p=0.05, partial ή(2)=0.07).

CONCLUSIONS

The findings highlight the need for further research on the specific conditions under which massage might promote relaxation and improve mood for people with dementia. The unfamiliar research assistants and variations in usual activity may have contributed to the increase in agitation and this needs further research.

TRIAL REGISTRATION

ACTRN12612000658819.

Neurodevelopmental and psychiatric issues in Down's syndrome: assessment and intervention

Down's syndrome (DS) is the most frequent genetic cause of intellectual disability and patients with DS show significant psychopathology (18-23%). Moreover, individuals with DS often show a cognitive decline associated with ageing characterized by a deterioration in memory, language and cognitive functioning. According to these relevant findings, an overview is presented of state-of-the-art knowledge of the neurocognitive, neurobiological and psychopathological profile, assessment and treatment of patients with DS. The linguistic characteristics of DS develop differently along distinct developmental trajectories. Thus, for example, morphosyntax deficit, especially in production, is more evident in adolescence than in early childhood and lexicon is usually better preserved in all ages (at least in comprehension). So far, rehabilitation is the only effective approach for improving cognitive and linguistic abilities. However, ongoing preliminary reports on other approaches such as transmagnetic stimulation or drugs suggest alternative or integrative treatment for the future. Individuals with DS show typical organization of brain structures related to some cognitive abilities, such as reduced volume in frontal and prefrontal areas, which is related to poor executive and linguistic abilities. They also frequently show psychiatric disorders such as externalizing disorders as well as depression, anxiety and obsessive-compulsive disorder. Nevertheless, as for other genetic syndrome with intellectual disability, there is a significant lack of research specifically focused on treatments of psychiatric and behavioural problems in DS. This is true both for psychosocial and for pharmacological interventions.

The National Task Group on Intellectual Disabilities and Dementia Practices consensus recommendations for the evaluation and management of dementia in adults with intellectual disabilities

Adults with intellectual and developmental disabilities (I/DD) are increasingly presenting to their health care professionals with concerns related to growing older. One particularly challenging clinical question is related to the evaluation of suspected cognitive decline or dementia in older adults with I/DD, a question that most physicians feel ill-prepared to answer. The National Task Group on Intellectual Disabilities and Dementia Practices was convened to help formally address this topic, which remains largely underrepresented in the medical literature. The task group, comprising specialists who work extensively with adults with I/DD, has promulgated the following Consensus Recommendations for the Evaluation and Management of Dementia in Adults With Intellectual Disabilities as a framework for the practicing physician who seeks to approach this clinical question practically, thoughtfully, and comprehensively.

Scales for the evaluation of end-of-life care in advanced dementia: sensitivity to change

The paucity of valid and reliable instruments designed to measure end-of-life experiences limits advanced dementia and palliative care research. Two end-of-life in dementia (EOLD) scales that evaluate the experiences of severely cognitively impaired persons and their health care proxies (HCP) have been developed: (1) symptom management (SM) and (2) satisfaction with care (SWC). The aim of this study was to examine the sensitivity of the EOLD scales in detecting significant differences in clinically relevant outcomes in nursing home residents with advanced dementia. The SM-EOLD scale was sensitive to detecting changes in comfort among residents with pneumonia, pain, dyspnea, and receiving burdensome interventions. The SWC-EOLD scale was sensitive to detecting changes in HCP satisfaction with the care of residents when addressing whether the health care provider spent >15 minutes discussing the resident's advanced care planning, whether the physician counseled about the resident's live expectancy, whether the resident resided in a special care unit, and whether the physician counseled possible resident health problems. This study extends the psychometric properties of the EOLD scales by showing the sensitivity to clinically meaningful change in these scales to specific outcomes related to end-of-life care and quality of life among residents with end-stage advanced dementia and their HCPs.

Brief cognitive assessment of Alzheimer's disease in advanced stages: Proposal for a Brazilian version of the Short Battery for Severe Impairment (SIB-8)

The measurement of cognitive abilities of patients with severe dementia can serve a wide range of methodological and clinical needs.

Incidence of dementia in older adults with intellectual disabilities

Dementia may be more common in older adults with intellectual disability (ID) than in the general population. The increased risk for Alzheimer's disease in people with Down syndrome (DS) is well established, but much less is known about dementia in adults with ID who do not have DS. We estimated incidence rates from a longitudinal study of dementia in older adults with ID without DS and compared them to general population rates. 222 participants with ID without DS aged 60 years and older were followed up an average of 2.9 years later to identify those who had declined in functional or cognitive abilities. Those who screened positive had a comprehensive assessment for dementia, diagnosed using ICD 10 and DSM IV criteria. 134 participants who did not have dementia at initial assessment were alive and interviewed at follow up; 21 (15.7%) were diagnosed with dementia. Overall incidence rate for those aged ≥ 60 was 54.6/1000 person years (95% CI 34.1-82.3). The highest incidence rate (97.8/1000 person years) was in the age group 70-74. Standardised incidence ratio for those aged ≥ 65 was 4.98 (95% CI 1.62-11.67). Incidence of dementia in older people with intellectual disabilities are up to five times higher than older adults in the general population. Screening may be useful in this population given the high incident rates, particularly as more effective treatments become available. Studies to explore the underlying aetiological factors for dementia associated with intellectual disability could help to identify novel protective and risk factors.

Validity of criteria for dementia in older people with intellectual disability

OBJECTIVE

Valid definitions of dementia should discriminate dementia from other forms of cognitive impairment such as intellectual disability (ID). We aimed to evaluate the usefulness of criteria for dementia and mild cognitive impairment (MCI) in ID, including predictive validity, and inter-rater reliability.

METHOD

We assessed 222 participants in a survey of older adults with ID without Down syndrome at two time points for dementia (T1 and T2). Mean follow-up period was 2.9 years. Dementia diagnoses were made according to International Classification of Diseases, Tenth Revision, Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), Diagnostic criteria for psychiatric disorders for use with adults with learning disabilities (DC-LD) criteria. At follow-up (T2), raters were blind to initial diagnosis. Predictive validity was determined by comparing odds ratios (ORs) of death, or of having a "poor outcome" (i.e., either dying or being diagnosed with dementia at T2).

RESULTS

All dementia criteria showed substantial inter-rater reliability (κ > 0.68) and high specificity (~95%). Dementia cases at T1 were more likely to have died at T2 than those with no dementia (33.3% versus 14.9%; OR: 2.85; 95% confidence interval (95% CI): 1.12-7.22) and to have a "poor outcome" (77.8% versus 27.6%; OR: 9.18; 95% CI: 3.43-24.53). At least two dementia cases at T1 were false positives. Those with "MCI" at T1 were similar to "no dementia" cases in terms of poor outcomes at T2.

CONCLUSION

Dementia diagnostic criteria show substantial reliability and satisfactory validity in ID. The diagnoses were, however, less stable than in the general population and some caution is advisable in those with more severe ID or additional sensory disability. MCI definitions require further consideration in the ID population.

Recommended measures for the assessment of cognitive and physical performance in older patients with dementia: a systematic review

Aim/Goal

To recommend a set of neuropsychological and physical exercise tests for researchers to assess cognition and physical fitness in clinical trials with older patients with dementia; to create consensus, decrease heterogeneity, and improve research quality.

Methods

A literature search (2005–2011) yielded 89 randomized controlled trials. To provide information on test recommendations the frequency of test use, effect size of the test outcome, study quality, and psychometric properties of tests were analyzed.

Results

Fifty-nine neuropsychological tests (cognitive domains: global cognition, executive functioning, memory, and attention) and 10 exercise tests (physical domains: endurance capacity, muscle strength, balance, and mobility) were found.

Conclusion

The Severe Impairment Battery, Mini Mental State Examination, and Alzheimer Disease Assessment Scale – cognitive subscale were recommended to measure global cognition. The Verbal Fluency Test Category/Letters, Clock Drawing Test, and Trail Making Test-B were recommended to measure executive functioning. No specific memory test could be recommended. The Digit Span Forward, Digit Span Backward, and Trail Making Test-A were recommended to measure attention. As physical exercise tests, the Timed Up and Go and Six Meter Walk for mobility, the Six Minute Walk Distance for endurance capacity, and the Tinetti Balance Scale were recommended.

From Alzheimer's disease retrogenesis: a new care strategy for patients with advanced dementia

There is evidence that exercise may reduce the progressive cognitive dysfunction of Alzheimer's disease (AD). However, no previous investigation has studiethe acute effects of adapted games (AG) on patients with AD. The aim of this study was to examine the acute effects of AG on the agitated behavior (rating scale Agitated Behavior Rating Scale [ABRS]) and cognitive performance (Test for Severe Impairment [TSI]) of patients with advanced dementia. Twenty patients (83±4 yrs) participated in AG and placebo activities (PL). Agitated behavior and cognitive performance were compared before and after 30 minutes of AG and PL. In the hour after the AG, agitated behavior decreased by ∼4 ABRS points and cognitive performance increased by ∼5 TSI points. On the contrary, after PL we found no change in agitated behavior or cognitive performance. Our data indicate that AG can momentarily reduce agitated behavior and increase the cognitive performance in participants with AD.

The study of pathogen resistance and antimicrobial use in dementia: study design and methodology

Advanced dementia is characterized by the onset of infections and antimicrobial use is extensive. The extent to which this antimicrobial use is appropriate and contributes to the emergence of antimicrobial resistant bacteria is not known. The object of this report is to present the methodology established in the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia (SPREAD), and describe how challenges specific to this research were met. SPREAD is an ongoing, federally funded, 5-year prospective cohort study initiated in September 2009. Subjects include nursing home residents with advanced dementia and their proxies recruited from 31 Boston-area facilities. The recruitment and data collection protocols are described. Characteristics of participant facilities are presented and compared to those nationwide. To date, 295 resident/proxy dyads have been recruited. Baseline and selected follow-up data demonstrate successful recruitment of subjects and repeated collection of complex data documenting infections, decision-making for these infections, and antimicrobial bacteria resistance among the residents. SPREAD integrates methods in dementia, palliative care and infectious diseases research. Its successful implementation further establishes the feasibility of conducting rigorous, multi-site NH research in advanced dementia, and the described methodology serves as a detailed reference for subsequent publications emanating from the study.

A useful and brief cognitive assessment for advanced dementia in a population with low levels of education

BACKGROUND/AIMS

Almost half of community-dwelling patients and 59.6% of institutionalized residents with dementia are in moderate or severe stages of this disease. The Mini-Mental State Examination (MMSE) has limited applicability to these patients due to floor effects. We aimed to determine the correlation between the MMSE and the Severe Mini-Mental State Examination (SMMSE), as well as SMMSE association with functional scales in patients having moderate to severe dementia and low levels of education.

METHODS

A cross-sectional study of patients 60 years or older attending an outpatient clinic was conducted. The MMSE, SMMSE and functional scales were applied. Clinical and demographic data from medical records were reviewed.

RESULTS

Seventy-five patients with a mean of 4.1±3.6 years of education were analyzed. The mean scores on the MMSE and SMMSE were 7.8±7.0 and 17.8±9.4, respectively. The results indicated that the MMSE and SMMSE correlated only in patients who had an MMSE score of less than 10 (r=0.87; p<0.001). In addition, significant correlations were found between the SMMSE and functional scales (p<0.001). It was observed that educational level did not interact with SMMSE performance.

CONCLUSION

The SMMSE is a useful and reliable tool for a brief cognitive assessment of advanced dementia patients with low educational levels.

Domain-Specific Anosognosia in Alzheimer's Disease and Vascular Dementia

The present study investigated the relationship between anosognosia for cognitive, functional and psychopathological disorders in Alzheimer's disease (AD) and vascular dementia (VD). Ten patients with probable Alzheimer's disease and 10 patients with probable vascular dementia were matched for age, education, illness duration and dementia severity. Cognitive, functional and psychopathological characteristics of the patients were assessed by means of different self-rating scales. The same questionnaires were submitted to patients' caregivers, blind to the patients' answers. Anosognosia was defined as the positively signed difference between patients' and caregivers' ratings. Three anosognosia indices for each domain investigated were obtained. We found lack of insight to be a common and consistent feature of AD and VD. However, unawareness for cognitive and functional domains was more severe in AD than in VD. Furthermore, in AD patients anosognosia for cognitive, functional and psychopathological domains dissociated from one another, as shown by lack of significant correlations between the three indices. Conversely, in VD patients these three anosognosic domains were closely related, indicating a generalised unawareness. These findings suggest that heterogeneity of anosognosic deficits may help differentiate AD from VD.

Mental health and exposure to patient distress among families of nursing home residents with advanced dementia

CONTEXT

The effect of suffering among patients with advanced dementia on their family members' mental health has not been investigated.

OBJECTIVES

To describe family members' exposure to distressing symptoms among nursing home (NH) residents with advanced dementia and associations between such exposure and family members' mental health.

METHODS

Data were obtained from an 18-month prospective cohort study of NH residents with advanced dementia and their family member health care proxies (HCPs). Exposure to resident symptoms and associated fear and helplessness was measured quarterly using the Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) scale (range 0-120). HCP mental health was assessed quarterly using the Composite International Diagnostic Interview Short Form (CIDI-SF) (depression), K6 (psychological distress, range 0-24), and SF-12(®) mental health subscale.

RESULTS

Seven hundred seventy-nine SCARED scale assessments were completed by 225 HCPs. The most frequent distressing symptoms were the following: feeling the resident had had enough (33.2%), choking (21.1%), and pain (18.9%). The symptoms eliciting the greatest fear were thinking the resident was dead and seeing them choke. A sense of helplessness was highest when the resident was observed to be in pain or choking. Family members with SCARED scores >0 were more likely to meet criteria for depression on the CIDI-SF (adjusted odds ratio [AOR] 2.59, 95% confidence interval [CI] 1.14, 5.85), have a K6 score >0 (AOR 2.31, 95% CI 1.55, 3.43), and have lower SF-12 scores (adjusted parameter estimate -1.51, 95% CI -2.56, -0.47).

CONCLUSION

Family member exposure to distressing symptoms experienced by their loved ones with advanced dementia is not uncommon and is associated with worse mental health.

Medicare expenditures among nursing home residents with advanced dementia

BACKGROUND

Nursing home residents with advanced dementia commonly experience burdensome and costly interventions (eg, tube feeding) that may be of limited clinical benefit. To our knowledge, Medicare expenditures have not been extensively described in this population.

METHODS

Nursing home residents with advanced dementia in 22 facilities (N = 323) were followed up for 18 months. Clinical and health services use data were collected every 90 days. Medicare expenditures were described. Multivariate analysis was used to identify factors associated with total 90-day expenditures for (1) all Medicare services and (2) all Medicare services excluding hospice.

RESULTS

Over an 18-month period, total mean Medicare expenditures were $2303 per 90 days but were highly skewed; expenditures were less than $500 for 77.1% of the 90-day assessment periods and more than $12,000 for 5.5% of these periods. The largest proportion of Medicare expenditures were for hospitalizations (30.2%) and hospice (45.6%). Among decedents (n = 177), mean Medicare expenditures increased by 65% in each of the last 4 quarters before death owing to an increase in both acute care and hospice. After multivariable adjustment, not living in a special care dementia unit was a modifiable factor associated with higher total expenditures for all Medicare services. Lack of a do-not-hospitalize order, tube feeding, and not living in a special care unit were associated with higher nonhospice Medicare expenditures.

CONCLUSIONS

Medicare expenditures among nursing home residents with advanced dementia vary substantially. Hospitalizations and hospice account for most spending. Strategies that promote high-quality palliative care may shift expenditures away from aggressive treatments for these patients at the end of life.

[Short evaluation of cognitive state in advanced stages of dementia: preliminary results of the Spanish validation of the Severe Mini-Mental State Examination]

INTRODUCTION

The cognitive assessment of patients with advanced dementia needs proper screening instruments that allow obtain information about the cognitive state and resources that these individuals still have. The present work conducts a Spanish validation study of the Severe Mini Mental State Examination (SMMSE).

MATERIAL AND METHODS

Forty-seven patients with advanced dementia (Mini-Cognitive Examination [MEC]<11) were evaluated with the Reisberg's Global Deterioration Scale, MEC, SMMSE and Severe Cognitive Impairment Profile scales.

RESULTS

All test items were discriminative. The test showed high internal (α=0.88), test-retest (0.64 to 1.00, P<.01) and between observers reliabilities (0.69-1.00, p<0.01), both for scores total and for each item separately. Construct validity was tested through correlations between the instrument and MEC scores (r=0.59, P<0.01). Further information on the construct validity was obtained by dividing the sample into groups that scored above or below 5 points in the MEC and recalculating their correlations with SMMSE. The correlation between the scores in the SMMSE and MEC was significant in the MEC 0-5 group (r=0.55, P<.05), but not in the MEC>5 group. Additionally, differences in scores were found in the SMMSE, but not in the MEC, between the three GDS groups (5, 6 and 7) (H=11.1, P<.05).

CONCLUSIONS

The SMMSE is an instrument for the assessment of advanced cognitive impairment which prevents the floor effect through an extension of lower measurement range relative to that of the MEC. From our results, this rapid screening tool and easy to administer, can be considered valid and reliable.

Hospice use and outcomes in nursing home residents with advanced dementia

OBJECTIVES

To identify characteristics of nursing home (NH) residents with advanced dementia and their healthcare proxies (HCPs) associated with hospice referral and to examine the association between hospice use and the treatment of pain and dyspnea and unmet needs during the last 7 days of life.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia and their HCPs.

MEASUREMENTS

Data were collected at baseline and quarterly for up to 18 months. Hospice referral, frequency of pain and dyspnea, and treatment of these symptoms was ascertained. HCPs reported unmet needs during the last 7 days of the residents' lives for communication, information, emotional support, and help with personal care.

RESULTS

Twenty-two percent of residents were referred to hospice. After multivariable adjustment, factors associated with hospice referral were nonwhite race, eating problems, HCP's perception that the resident's had less than 6 months to live, and better HCP mental health. Residents in hospice were more likely to receive scheduled opioids for pain (adjusted odds ratio (AOR)=3.16; 95% confidence interval (95% CI)=1.57-6.36) and oxygen, morphine, scopolamine, or hyoscyamine for dyspnea (AOR=3.28, 95% CI=1.37-7.86). HCPs of residents in hospice reported fewer unmet needs in all domains during the last 7 days of the residents' life.

CONCLUSION

A minority of NH residents with advanced dementia received hospice care. Hospice recipients were more likely to received scheduled opioids for pain and symptomatic treatment for dyspnea and had fewer unmet needs at the end of life.

A pilot study of a test for visual recognition memory in adults with moderate to severe intellectual disability

Objective assessment of memory functioning is an important part of evaluation for Dementia of Alzheimer Type (DAT). The revised Picture Recognition Memory Test (r-PRMT) is a test for visual recognition memory to assess memory functioning of persons with intellectual disabilities (ID), specifically targeting moderate to severe ID. A pilot study was performed to investigate whether the r-PRMT could differentiate DAT-related memory decline from pre-existing poor memory functioning of persons with moderate to severe ID. The r-PRMT scores were compared between 26 participants with DAT and moderate to severe ID and 33 controls with similar levels of ID. The results revealed that the controls with DS showed uniformly high scores in contrast to those with DAT on the r-PRMT and the score distributions of two groups were distinctly different with no overlap. On the other hand, the controls with non-DS etiologies scored much lower with a wider score spread, resulting in significant overlap with the score distribution of the participants with DAT. In conclusion, the r-PRMT may be effective in identifying persons with DAT among persons with moderate to severe ID from DS. However, the r-PRMT may result in a high false positive error rate in discriminating those with DAT among persons with moderate to severe ID from non-DS etiologies, if the judgment is based on a single point assessment.

Survival and comfort after treatment of pneumonia in advanced dementia

BACKGROUND

Pneumonia is common among patients with advanced dementia, especially toward the end of life. Whether antimicrobial treatment improves survival or comfort is not well understood. The objective of this study was to examine the effect of antimicrobial treatment for suspected pneumonia on survival and comfort in patients with advanced dementia.

METHODS

From 2003 to 2009, data were prospectively collected from 323 nursing home residents with advanced dementia in 22 facilities in the area of Boston, Massachusetts. Each resident was followed up for as long as 18 months or until death. All suspected pneumonia episodes were ascertained, and antimicrobial treatment for each episode was categorized as none, oral only, intramuscular only, or intravenous (or hospitalization). Multivariable methods were used to adjust for differences among episodes in each treatment group. The main outcome measures were survival and comfort (scored according to the Symptom Management at End-of-Life in Dementia scale) after suspected pneumonia episodes.

RESULTS

Residents experienced 225 suspected pneumonia episodes, which were treated with antimicrobial agents as follows: none, 8.9%; oral only, 55.1%, intramuscular, 15.6%, and intravenous (or hospitalization), 20.4%. After multivariable adjustment, all antimicrobial treatments improved survival after pneumonia compared with no treatment: oral (adjusted hazard ratio [AHR], 0.20; 95% confidence interval [CI], 0.10-0.37), intramuscular (AHR, 0.26; 95% CI, 0.12-0.57), and intravenous (or hospitalization) (AHR, 0.20; 95% CI, 0.09-0.42). After multivariable adjustment, residents receiving any form of antimicrobial treatment for pneumonia had lower scores on the Symptom Management at End-of-Life in Dementia scale (worse comfort) compared with untreated residents.

CONCLUSION

Antimicrobial treatment of suspected pneumonia episodes is associated with prolonged survival but not with improved comfort in nursing home residents with advanced dementia.

Daily medication use in nursing home residents with advanced dementia

OBJECTIVES

To describe the pattern and factors associated with daily medication use in nursing home (NH) residents with advanced dementia.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

NH residents with advanced dementia (N=323).

MEASUREMENTS

Data from residents' records were used to determine the number or daily medications, specific drugs prescribed, and use of drugs deemed "never appropriate" in patients with advanced dementia. Resident characteristics associated with the use of more daily medications and drugs deemed inappropriate were examined.

RESULTS

Residents were prescribed a mean of 5.9 +/- 3.0 daily medications, and 37.5% received at least one medication considered "never appropriate" in advanced dementia. Acetylcholinesterase inhibitors (15.8%) and lipid-lowering agents (12.1%) were the most common inappropriate drugs. Twenty-eight percent of residents took antipsychotics daily. Modest reductions in most daily medications occurred only during the last week of life. Factors independently associated with taking more daily medications included older age, male sex, non-white race, dementia not due to Alzheimer's disease, better cognition, cardiovascular disease, acute illness, and hospice referral. Factors independently associated with greater likelihood of taking inappropriate medications included being male, shorter NH stay, better functional status, and diabetes mellitus, whereas a do-not-hospitalize order was associated with a lower likelihood.

CONCLUSION

Questionably beneficial medications are common in advanced dementia, even as death approaches. Several characteristics can help identify residents at risk for greater medication burden. Medication use in advanced dementia should be tailored to the goals of care.

The Functional Transitions Model: Maximizing Ability in the Context of Progressive Disability Associated with Alzheimer's Disease

The Functional Transitions Model (FTM) integrates the theoretical notions of progressive functional decline associated with Alzheimer's disease (AD), excess disability, and transitions occurring intermittently along the trajectory of functional decline. Application of the Functional Transitions Model to clinical practice encompasses the paradox of attempting to minimize excess disability while anticipating the progressive functional decline associated with AD. It is suggested that times of functional transition are times of decision making and opportunities for interdisciplinary collaboration to identify and minimize excess disability, for revision of goals and expectations, and for provision of support to patients and caregivers. The model also is applicable as a conceptual framework for education and research.

The Degree of Bedroom Personalization in Institutional and Homelike Settings for Persons with Dementia: A Quantitative Investigation

The purpose of this study was to provide an empirical measure of bedroom personalization and a descriptive characterization of the types of items included in a personalized space. The study compared the extent of personalization in three types of bedrooms, varying as to their homelike quality (private-homelike, private-institutional, and ward-institutional). A measure of the relative degree of personalization was obtained by recording the number of personal items for each room and dividing the number of items per room by each room's available vertical and horizontal surface area. The degree of personalization was found to be significantly greater in private-homelike rooms than in private-institutional or ward-institutional rooms. This study provides the first demonstration that personalization of a resident's bedroom can be quantified and opens the way for studies of factors contributing to the effect (e.g., facility regulations, family, and staff attitudes) and empirical studies of presumed consequences (e.g., resident satisfaction and improved functioning).

Tract-specific and region of interest analysis of corticospinal tract integrity in subcortical ischemic stroke: reliability and correlation with motor function of affected lower extremity

BACKGROUND AND PURPOSE

TS analysis has been suggested as a useful method to evaluate the fiber integrity of white matter tracts. This study investigated the intrarater and interrater reliability and validity of a TS analysis for the CST and compared the results with those of a ROI-based analysis.

MATERIALS AND METHODS

Diffusion spectrum imaging was performed on 7 patients with subcortical ischemic stroke on a 3T MR imaging system. For the TS analysis, seed regions were placed at the cerebral peduncle and the medial portion of the primary motor cortex to reconstruct the tracts of the CST for motor control of the lower extremity. The mean GFA was measured at the PLIC by calculating the weighted sum of the GFAs sampled by the CST tracts at this segment. For the ROI-based analysis, the posterior two-thirds of the PLIC were enclosed on the GFA maps, and the mean GFA in this ROI was calculated.

RESULTS

The results showed good-to-excellent intrarater and interrater reliability on the seed region/ROI placement (mean kappa values >0.80) and mean GFA values (ICCs >0.90) for both the TS and ROI-based analyses. Both the GFA(PLIC-TS) and GFA(PLIC-ROI) values were highly correlated with the motor function of the affected lower extremity (r = 0.76 and 0.80, respectively; P < .05).

CONCLUSIONS

We demonstrated good reliability and validity of the TS and ROI-based analyses of the CST corresponding to lower extremity motor control in patients with subcortical ischemic stroke.

Comparing the functional independence measure and the interRAI/MDS for use in the functional assessment of older adults: a review of the literature

BACKGROUND

The rehabilitation of older persons is often complicated by increased frailty and medical complexity - these in turn present challenges for the development of health information systems. Objective investigation and comparison of the effectiveness of geriatric rehabilitation services requires information systems that are comprehensive, reliable, valid, and sensitive to clinically relevant changes in older persons. The Functional Independence Measure is widely used in rehabilitation settings - in Canada this is used as the central component of the National Rehabilitation Reporting System of the Canadian Institute of Health Information. An alternative system has been developed by the interRAI consortium. We conducted a literature review to compare the development and measurement properties of these two systems.

METHODS

English language literature published between 1983 (initial development of the FIM) and 2008 was searched using Medline and CINAHL databases, and the reference lists of retrieved articles. Relevant articles were summarized and charted using the criteria proposed by Streiner. Additionally, attention was paid to the ability of the two systems to address issues particularly relevant to older rehabilitation clients, such as medical complexity, comorbidity, and responsiveness to small but clinically meaningful improvements.

RESULTS

In total, 66 articles were found that met the inclusion criteria. The majority of FIM articles studied inpatient rehabilitation settings; while the majority of interRAI/MDS articles focused on nursing home settings. There is evidence supporting the reliability of both instruments. There were few articles that investigated the construct validity of the interRAI/MDS.

CONCLUSION

Additional psychometric research is needed on both the FIM and MDS, especially with regard to their use in different settings and with different client groups.

The clinical course of advanced dementia

BACKGROUND

Dementia is a leading cause of death in the United States but is underrecognized as a terminal illness. The clinical course of nursing home residents with advanced dementia has not been well described.

METHODS

We followed 323 nursing home residents with advanced dementia and their health care proxies for 18 months in 22 nursing homes. Data were collected to characterize the residents' survival, clinical complications, symptoms, and treatments and to determine the proxies' understanding of the residents' prognosis and the clinical complications expected in patients with advanced dementia.

RESULTS

Over a period of 18 months, 54.8% of the residents died. The probability of pneumonia was 41.1%; a febrile episode, 52.6%; and an eating problem, 85.8%. After adjustment for age, sex, and disease duration, the 6-month mortality rate for residents who had pneumonia was 46.7%; a febrile episode, 44.5%; and an eating problem, 38.6%. Distressing symptoms, including dyspnea (46.0%) and pain (39.1%), were common. In the last 3 months of life, 40.7% of residents underwent at least one burdensome intervention (hospitalization, emergency room visit, parenteral therapy, or tube feeding). Residents whose proxies had an understanding of the poor prognosis and clinical complications expected in advanced dementia were much less likely to have burdensome interventions in the last 3 months of life than were residents whose proxies did not have this understanding (adjusted odds ratio, 0.12; 95% confidence interval, 0.04 to 0.37).

CONCLUSIONS

Pneumonia, febrile episodes, and eating problems are frequent complications in patients with advanced dementia, and these complications are associated with high 6-month mortality rates. Distressing symptoms and burdensome interventions are also common among such patients. Patients with health care proxies who have an understanding of the prognosis and clinical course are likely to receive less aggressive care near the end of life.

Healthcare proxies of nursing home residents with advanced dementia: decisions they confront and their satisfaction with decision-making

OBJECTIVES

To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision-making satisfaction.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia and their HCPs.

MEASUREMENTS

Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0-100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction).

RESULTS

Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score +/- standard deviation was 78.4 +/- 19.5, indicating high overall satisfaction. NH provider involvement in shared decision-making was the area of least satisfaction. In adjusted analysis, greater decision-making satisfaction was associated with the resident living on a special care dementia unit (P=.002), greater resident comfort (P=.004), and the HCP not being the resident's child (P=.02).

CONCLUSION

HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision-making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision-making satisfaction.

Effects of changes in depressive symptoms and cognitive functioning on physical disability in home care elders

BACKGROUND

This study sought to investigate the effect of changes in depression status on physical disability in older persons receiving home care, examine whether the effect is due to concomitant changes in cognitive status, and test whether affective state and cognitive ability interact to influence physical disability.

METHODS

Multilevel analyses were conducted using longitudinal data collected about every 3 months from older participants in Michigan's community-based long-term care programs (N = 13,129). The data set provided an average of nine repeated measures of depressive symptoms, cognitive functioning, and physical disability. We estimated the lag effects of within-person changes in depression and cognitive status, and their interaction, on physical disability measured by activities of daily living (ADL) and instrumental activities of daily living (IADL), controlling for health-related events that occurred in the interim.

RESULTS

Changes between not having and having depressive symptoms, including subsyndromal symptoms, are critical to physical disability for home care elders. The effects are independent of concomitant changes in cognitive status, which also have significant adverse effects on physical disability. There is some evidence that improvement of depression buffers the adverse effect of cognitive decline on IADL disability.

CONCLUSIONS

Providers should monitor changes in depression and cognitive status in home care elders. Early detection and treatment of subthreshold depression, as well as efforts to prevent worsening of cognitive status in home care elders, may have a meaningful impact on their ability to live at home.

Memantine for dementia in people with Down syndrome

BACKGROUND

Alzheimer's dementia (AD) is the most common form of dementia in people with Down Syndrome (DS). There is an understanding that an increase in L-glutamate contributes to the pathogenesis of cerebral ischemias and AD. Memantine acts as an antagonist of N-methyl-D-aspartate (NMDA) type receptors, which is thought to reduce abnormal activation of glutamate neurotransmission. It binds with a low affinity to the NMDA receptor and so should not prevent learning and the formation of memory. Memantine can improve cognitive function and slow the decline of AD in the general population over time, and is the subject of this review. It is important to note that people with DS tend to present with AD at a much younger age than the normal population as well as having subtle differences in physiology (e.g. metabolism and heart rate) and may therefore have different requirements from the general population.

OBJECTIVES

To determine the effectiveness and safety of memantine for people with DS who develop AD.

SEARCH STRATEGY

CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS, SCI, SSCI and the NRR were searched up to October 2008. We contacted the manufacturers of memantine, as well as experts in the field, to ask about reports of unpublished or ongoing trials.

SELECTION CRITERIA

Randomised controlled trials of participants with DS and AD in which treatment with memantine was administered compared with a placebo group.

DATA COLLECTION AND ANALYSIS

No study was identified which met the inclusion criteria for this review.

MAIN RESULTS

No study was identified which met inclusion criteria for this review, however there is an on-going randomised controlled study being conducted in the UK and data are expected in 2009.

AUTHORS' CONCLUSIONS

As there are no included trials, recommendations cannot be made about memantine for AD in DS. Well-designed, adequately powered studies are required.

Rivastigmine for dementia in people with Down syndrome

BACKGROUND

Alzheimer's dementia (AD) is the most common form of dementia in people with Down Syndrome (DS). Acetylcholine is a chemical found in the brain that has an important role in memory, attention, reason and language. Rivastigmine is a "pseudo-irreversible" inhibitor of acetylcholinesterase, which is thought to maintain levels of acetylcholine. Rivastigmine can improve cognitive function and slow the decline of AD in the general population over time. It is important to note that people with DS tend to present with AD at a much younger age than the normal population as well as having subtle differences in physiology (e.g. metabolism and heart rate) and may therefore have different requirements from the general population.

OBJECTIVES

To determine the effectiveness and safety of rivastigmine for people with DS who develop AD.

SEARCH STRATEGY

CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS, SCI, SSCI and the NRR were searched up to October 2008. We contacted the manufacturers of rivastigmine as well as experts in the field, to ask about reports of unpublished or ongoing trials.

SELECTION CRITERIA

Randomised controlled trials of participants with DS and AD in which treatment with rivastigmine was administered compared with a placebo group.

DATA COLLECTION AND ANALYSIS

No study was identified which met inclusion criteria for this review.

MAIN RESULTS

No study was identified which met inclusion criteria for this review.

AUTHORS' CONCLUSIONS

As there are no included trials, recommendations cannot be made about rivastigmine for AD in DS. Well-designed, adequately powered studies are required.

Galantamine for dementia in people with Down syndrome

BACKGROUND

Alzheimer's dementia (AD) is the most common form of dementia in people with Down Syndrome (DS). Acetylcholine is a chemical found in the brain that has an important role in memory, attention, reason and language. Galantamine both inhibits the activity of acetylcholinesterase and increases the level of acetylcholine. Galantamine can improve cognitive function and slow the decline of AD in the general population over time. It is important to note that people with DS tend to present with AD at a much younger age than the normal population as well as having subtle differences in physiology (e.g. metabolism and heart rate) and may therefore have different requirements from the general population.

OBJECTIVES

To determine the effectiveness and safety of galantamine for people with DS who develop AD.

SEARCH STRATEGY

CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS, SCI, SSCI and the NRR were searched up to October 2008. We contacted the manufacturers of galantamine as well as experts in the field, to ask about reports of unpublished or ongoing trials.

SELECTION CRITERIA

Randomised controlled trials of participants with DS and AD in which treatment with galantamine was administered compared with a placebo group.

DATA COLLECTION AND ANALYSIS

No study was identified which met inclusion criteria for this review.

MAIN RESULTS

No study was identified which met inclusion criteria for this review.

AUTHORS' CONCLUSIONS

As there are no included trials, recommendations cannot be made about galantamine for AD in DS. Well-designed, adequately powered studies are required.

Donepezil for dementia in people with Down syndrome

BACKGROUND

Alzheimer's dementia (AD) is the most common form of dementia in people with Down Syndrome [DS]. Acetylcholine is a chemical found in the brain that has an important role in memory, attention, reason and language. Donepezil a reversible inhibitor of acetylcholinesterase, which is thought to maintain levels of acetylcholine, and is reported to have some benefits for people with AD in the general population. It is important to note that people with DS tend to present with AD at a much younger age than the normal population as well as having subtle differences in physiology (e.g. metabolism and heart rate) and may therefore have different requirements from the general population.

OBJECTIVES

To determine the effectiveness and safety of donepezil for people with DS who develop AD.

SEARCH STRATEGY

CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, BIOSIS, SCI, SSCI and the NRR were searched up to October 2008. We contacted the manufacturers of donepezil as well as experts in the field, to ask about reports of unpublished or ongoing trials.

SELECTION CRITERIA

Randomised controlled trials of participants with DS and AD in which treatment with donepezil was administered compared with a placebo group.

DATA COLLECTION AND ANALYSIS

Data were extracted from the published reports of the one relevant study identified.

MAIN RESULTS

The one study included in this review is a small (n=30) randomised controlled trial lasting 24 weeks. It was followed-up by an open label study with a crossover design.No significant differences were found on any four validated outcomes including global functioning and three measures of cognitive abilities and behavioural problems. 6 out of 16 carers (37%) of participants on donepezil and 2 out of 15 (13%) on placebo reported improvement. No data were available for day to day skills, institutionalisation, reduction in carers' stress or economic outcomes. Half the intervention group and 20% of the placebo group reported adverse events; two participants left because of adverse events.

AUTHORS' CONCLUSIONS

To date there is only one small randomised controlled study on the effect of donepezil. This shows, at best, a modest, non statistically significant trend in favour of people with Down syndrome and Alzheimer's dementia who are able to tolerate donepezil (this drug is currently only dispensed in relatively large doses and is contraindicated for those with cardiac and respiratory problems).This study does not provide good evidence on which to base practice. Findings in an open-label follow up to this study suggest possible benefit in some individuals. Further, larger randomised controlled studies with longer-term follow up are required.

The relationship of dementia prevalence in older adults with intellectual disability (ID) to age and severity of ID

BACKGROUND

Previous research has shown that adults with intellectual disability (ID) may be more at risk of developing dementia in old age than expected. However, the effect of age and ID severity on dementia prevalence rates has never been reported. We investigated the predictions that older adults with ID should have high prevalence rates of dementia that differ between ID severity groups and that the age-associated risk should be shifted to a younger age relative to the general population.

METHOD

A two-staged epidemiological survey of 281 adults with ID without Down syndrome (DS) aged 60 years; participants who screened positive with a memory task, informant-reported change in function or with the Dementia Questionnaire for Persons with Mental Retardation (DMR) underwent a detailed assessment. Diagnoses were made by psychiatrists according to international criteria. Prevalence rates were compared with UK prevalence and European consensus rates using standardized morbidity ratios (SMRs).

RESULTS

Dementia was more common in this population (prevalence of 18.3%, SMR 2.77 in those aged 65 years). Prevalence rates did not differ between mild, moderate and severe ID groups. Age was a strong risk factor and was not influenced by sex or ID severity. As predicted, SMRs were higher for younger age groups compared to older age groups, indicating a relative shift in age-associated risk.

CONCLUSIONS

Criteria-defined dementia is 2-3 times more common in the ID population, with a shift in risk to younger age groups compared to the general population.