Comorbidity in dementia: an autopsy study

Glial cell dysregulation: a new perspective on Alzheimer disease

Alzheimer disease (AD) is a major cause of dementia. Several mechanisms have been postulated to explain its pathogenesis, beta-amyloid (A beta toxicity, cholinergic dysfunction, Tau hyper-phosphorylation, oxidative damage, synaptic dysfunction and inflammation secondary to senile plaques, among others. Glial cells are the major producers of inflammatory mediators, and cytotoxic activation of glial cells is linked to several neurodegenerative diseases; however, whether inflammation is a consequence or the cause of neurodegeneration is still unclear. I propose that inflammation and cellular stress associated with aging are key events in the development of AD through the induction of glial dysfunction. Dysregulated inflammatory response can elicit glial cell activation by compounds which are normally poorly reactive. Inflammation can also be the major cause of defective handling of A beta and the amyloid precursor protein (APP). Here I review evidence that support the proposal that dysfunctional glia and the resulting neuroinflammation can explain many features of AD. Evidence supports the notion that damage caused by inflammation is not only a primary cause of neurodegeneration but also an inducer for the accumulation of A beta in AD. Dysfunctional glia can result in impaired neuronal function in AD, as well as in many progressive neurodegenerative disorders. We show that microglial cell activation is enhanced under pro-inflammatory conditions, indicating that glial cell responses to A beta related proteins can be critically dependent on the priming of glial cells by pro-inflammatory factors.

Peripheral blood B lymphocytes derived from patients with idiopathic pulmonary arterial hypertension express a different RNA pattern compared with healthy controls: a cross sectional study

BACKGROUND

Idiopathic pulmonary arterial hypertension (IPAH) is a progressive and still incurable disease. Research of IPAH-pathogenesis is complicated by the lack of a direct access to the involved tissue, the human pulmonary vasculature. Various auto-antibodies have been described in the blood of patients with IPAH. The purpose of the present work was therefore to comparatively analyze peripheral blood B lymphocyte RNA expression characteristics in IPAH and healthy controls.

METHODS

Patients were diagnosed having IPAH according to WHO (mean pulmonary arterial pressure > or = 25 mmHg, pulmonary capillary occlusion pressure < or = 15 mmHg, absence of another explaining disease). Peripheral blood B-lymphocytes of patients and controls were immediately separated by density gradient centrifugation and magnetic beads for CD19. RNA was thereafter extracted and analyzed by the use of a high sensitivity gene chip (Affymetrix HG-U133-Plus2) able to analyze 47000 transcripts and variants of human genes. The array data were analyzed by two different softwares, and up-and down-regulations were defined as at least 1.3 fold with standard deviations smaller than fold-changes.

RESULTS

Highly purified B-cells of 5 patients with IPAH (mean pulmonary artery pressure 51 +/- 13 mmHg) and 5 controls were analyzed. Using the two different analyzing methods we found 225 respectively 128 transcripts which were up-regulated (1.3-30.7 fold) in IPAH compared with healthy controls. Combining both methods, there were 33 overlapping up-regulated transcripts and no down-regulated B-cell transcripts.

CONCLUSION

Patients with IPAH have a distinct RNA expression profile of their peripheral blood B-lymphocytes compared to healthy controls with some clearly up-regulated genes. Our finding suggests that in IPAH patients B cells are activated.

Demented versus non-demented very old inpatients: the same comorbidities but poorer functional and nutritional status

BACKGROUND

demented patients have been reported to be healthier than other old people of the same age.

OBJECTIVES

to assess comorbid conditions, functional and nutritional status in medically ill hospitalised patients with normal cognition or affected by dementia of various causes and severities, or mild cognitive impairment (MCI).

DESIGN AND SETTING

a prospective study was carried out, between January and December 2004, in the Rehabilitation and Geriatric Hospital (HOGER).

METHODS

activities of daily living (ADL), instrumental activities of daily living (IADL) and mini nutritional assessment (MNA) scores were assessed as a function of the status of the patient two weeks before admission to hospital. On admission, cognitive status was assessed by a systematic battery of neuropsychological tests, comorbid conditions were assessed with the Charlson comorbidity index (CCI), and body mass index (BMI) and functional independence measure (FIM) were determined. BMI and FIM were also determined on discharge.

RESULTS

we studied 349 patients (mean age 85.2 +/- 6.7; 76% women): 161 (46.1%) cognitively normal, 37 (10.6%) with MCI and 151 (43.3%) demented (61 Alzheimer's disease (AD), 62 mixed dementia (MD) and 17 vascular dementia (VaD)). ADL, IADL, FIM and MNA scores on admission decreased with cognitive status, regardless of the type of dementia. Functionality at discharge remained significantly lower in demented patients than in other patients. CCI was high and similar in all three groups (mean 4.6 +/- 2.7). Patients with VaD had poorer health than other demented patients, with a higher average comorbidity score, more frequent hypertension, stroke and hyperlipidaemia. Comorbidity did not increase with severity levels of dementia.

CONCLUSIONS

in this cohort of very old inpatients, demented patients, non-demented patients and patients with MCI had similar levels of comorbidity, but demented patients had a poorer functional and nutritional status.

Prevalence of Dementia Subtypes in El Prat de Llobregat, Catalonia, Spain: The PRATICON Study

BACKGROUND

Studies on dementia subtypes show a wide variation in the prevalence of Alzheimer's disease (AD) and vascular dementia (VD) worldwide. However, studies reporting on Lewy body dementia (LBD) and frontotemporal dementia (FTD) are sparse.

AIMS

To describe the prevalence of dementia and subtypes.

METHOD

A 34% sample of 5,150 subjects aged 70 years and over in El Prat de Llobregat (Barcelona) were screened by the Mini-Mental State Examination. When scoring <24, participants were assessed to establish a diagnosis.

RESULTS

There were 165 subjects diagnosed with dementia (prevalence of 9.4%). Subtypes of dementia were: AD 69.1%, VD 12.7%, LBD 9.1%, FTD 3% and secondary dementia 1.8%. Prevalences were: AD 6.5%, VD 1.2%, LBD 0.9% and FTD 0.3%.

CONCLUSIONS

AD and VD were the most common type of dementia. Prevalence of dementia, AD and FTD were similar to those reported, while prevalence of VD and LBD were lower.

Comprehensive geriatric assessment in elderly outpatients with dementia

Dementia is a common disabling disease in the elderly. In such patients, general health conditions may worsen the functional decline and loss of autonomy. The Comprehensive Geriatric Assessment (CGA) is a validated and recommended instrument for multidimensional evaluation of the aged. Nonetheless, it has yet to be assessed in demented patients.

OBJECTIVES

To analyze the functional, emotional and clinical status in elderly with dementia measured by the CGA. We also compared the results obtained in the same patients stratified for severity of dementia.

METHODS

Transversal study with demented elderly outpatients. Subjects were evaluated by the CGA consisting of clinical data, Clinical Dementia Rating, performance-oriented mobility assessment of gait and balance (POMA), Cornell scale for depression, activities of daily living, Mini Mental Status Examination (MMSE), Mini Nutritional Assessment, Whispered and Snellen Test.

RESULTS

Fifty-two patients with mean age of 77 years were evaluated. Majority of patients had Alzheimer disease (77%). Depression was the most prevalent comorbidity. The POMA score was related to the number of falls in the previous year. Also, there was correlation between complaints of visual and hearing impairment and the results on the Snellen and Whispered Tests. Regarding severity, 56% presented mild, 33% moderate and 11% severe condition. Patients with moderate/severe dementia had less leisure activities, greater risk of falls, along with worse performance on the MMSE, POMA and activities of daily living.

CONCLUSIONS

The CGA was applied in demented elderly with the help of their caregivers, and was able to better characterize patient state of health. Subjects with moderate/severe dementia obtained poor results in several assessed criteria.

Prediction of length of stay for stroke patients

OBJECTIVES

To examine the factors that influence acute and total length of stay (LOS) for stroke patients.

MATERIALS AND METHODS

The basis of this investigation was a population-based cohort of first-ever stroke patients (n = 388). Subjects were survivors of the initial hospitalization (n = 295). Age, sex, social factors, risk factors, dementia, stroke type, and stroke severity, measured with the NIH stroke scale (NIHSS), were registered.

RESULTS

Mean acute LOS was 12 days and mean total LOS was 29 days. Independent predictors of acute LOS were stroke severity, lacunar stroke, prestroke dementia, and smoking. Independent predictors of total LOS were stroke severity and prestroke activities of daily living (ADL) dependency. The NIHSS items that best correlated with LOS were paresis, unilateral neglect and level of consciousness.

CONCLUSIONS

Stroke severity is a strong and reliable predictor of LOS. The results of this study can be used as a baseline for evaluating cost-effectiveness of stroke care changes, e.g. organizational changes or evaluation of new drugs.

The 'natural' endpoint of dementia: death from cachexia or dehydration following palliative care?

OBJECTIVES

To investigate the causes of death in nursing home patients with dementia, and to compare causes of death in patients who survive until the final phase of dementia with those who die before reaching that phase, adjusted for potential confounders.

DESIGN

Observational analysis of a cohort of patients with a prospective follow-up.

SETTING

Psychogeriatric nursing home 'Joachim en Anna' in Nijmegen, the Netherlands.

PARTICIPANTS

Eight hundred and ninety dementia patients admitted between 1980 and 1989. All patients were followed until death.

MEASUREMENTS

The final phase of dementia was defined as total impairment on 20 items of a functional status questionnaire. Immediate causes of death (part 1a of the Dutch death certificate) were classified by the International Classification of Health Problems in Primary Care.

RESULTS

The three most important reported immediate causes of death were cachexia/dehydration (35.2%), cardio-vascular disorders (20.9%) and acute pulmonary diseases (20.1%), mainly pneumonia. Cachexia/dehydration was particularly common as a cause of death of patients who survived to the final phase (53.2%); survival to the final phase of dementia was an independent predictor of cachexia/dehydration as an immediate cause of death with reference to cardiovascular disorders in multinomial regression adjusted for age at death, gender, and type of dementia.

CONCLUSION

Patients who survive to the final phase of dementia are more likely to die from cachexia or dehydration than those who die before. The findings contribute to a debate on what should be reported as the immediate cause of death in dementia including perspectives from a palliative care viewpoint.

Early-onset Alzheimer's disease is associated with greater pathologic burden

Two subtypes of Alzheimer's disease (AD) have been commonly identified: early- and late-onset forms. Previous studies suggest that early-onset AD patients have more neuritic plaques (NPs) and neurofibrillary tangles (NFTs). In the current study, NP and NFT counts were performed for 8 brain regions in 25 subjects with definite AD. A repeated-measures analysis of variance of mean regional NP and NFT counts for early- and late-onset groups was performed. A significant between-subject effect indicating greater overall NP and NFT burden in the early-onset group was observed (NP: F = 6.8, df = 1, P = .015; NFT: F = 7.5, df = 1, P = .012). This analysis supports the hypothesis that early-onset AD is associated with greater pathologic burden than late-onset AD. This suggests that late-onset AD patients have less cognitive reserve than early-onset patients and require fewer pathologic changes to exhibit cognitive deterioration.

Health problems and correlates of pain in nursing home residents with advanced dementia

This study describes the health problems and comorbid illnesses of nursing home (NH) residents with advanced dementia (n=123) and identifies correlates of staff-identified pain. Study participants were residents of 3 NHs in Maryland, their surrogate decision makers and their physicians. Residents' cognitive function was assessed at study enrollment, and their medical records were reviewed to identify all health problems/illnesses and use of pain medications during the 6 months before their enrollment. The most prevalent health problems were skin problems (95%), nutrition/hydration problems (85%), psychiatric/behavioral problems (85%), gastrointestinal problems (81%), and infections (80%). Sixty-three percent of residents had recognized pain, and 95% of those residents received pain medications. In a multivariate regression analysis, staff-identified pain was associated with aspiration (P=0.008), peripheral vascular disease (P=0.021), musculoskeletal disorders (P=0.032), higher cognitive function (P=0.013), and use of pain medications, including non-opiates (P=0.004) and the combination of opiates and non-opiates (P=0.001). NH residents with advanced dementia experience a complex mixture of multiple chronic and acute comorbidities. These results suggest the need for clinicians in long-term care facilities to be vigilant in assessing and treating pain, particularly as cognitive function declines in those with advanced dementia.

Recommendations for the diagnosis and management of Alzheimer's disease and other disorders associated with dementia: EFNS guideline

The aim of this international guideline on dementia was to present a peer-reviewed evidence-based statement for the guidance of practice for clinical neurologists, geriatricians, psychiatrists, and other specialist physicians responsible for the care of patients with dementia. It covers major aspects of diagnostic evaluation and treatment, with particular emphasis on the type of patient often referred to the specialist physician. The main focus is Alzheimer's disease, but many of the recommendations apply to dementia disorders in general. The task force working group considered and classified evidence from original research reports, meta-analysis, and systematic reviews, published before January 2006. The evidence was classified and consensus recommendations graded according to the EFNS guidance. Where there was a lack of evidence, but clear consensus, good practice points were provided. The recommendations for clinical diagnosis, blood tests, neuroimaging, electroencephalography (EEG), cerebrospinal fluid (CSF) analysis, genetic testing, tissue biopsy, disclosure of diagnosis, treatment of Alzheimer's disease, and counselling and support for caregivers were all revised when compared with the previous EFNS guideline. New recommendations were added for the treatment of vascular dementia, Parkinson's disease dementia, and dementia with Lewy bodies, for monitoring treatment, for treatment of behavioural and psychological symptoms in dementia, and for legal issues. The specialist physician plays an important role together with primary care physicians in the multidisciplinary dementia teams, which have been established throughout Europe. This guideline may contribute to the definition of the role of the specialist physician in providing dementia health care.

Causes of Mortality on a University Hospital Neurology Service

BACKGROUND

The mortality rate for all patients cared for by inpatient neurology services has not been described.

METHODS

Quality assurance case discussions of all patients (n = 6012) admitted to a neurology service from 1996 to 2003 were reviewed to determine frequency and causes of mortality. All cases of mortality were reviewed in detail.

RESULTS

The majority of patients (98%) survived their admission; 118 patients died. In 95/118 cases, care had been withdrawn at the time of death. In 11 cases, adverse events occurred during the patients' hospital stay and may have impacted outcome. Few patients (18%) had clear advance directives.

CONCLUSION

Most mortality in this acute care neurology setting occurs in the course of stroke, epilepsy, or complicated tumor management and is managed through withdrawal of care with family participation.

Epidemiology of community-acquired pneumonia in adult patients at the dawn of the 21st century: a prospective study on the Mediterranean coast of Spain

This study presents data from a prospective study of adult patients with community-acquired pneumonia (CAP). Of 493 patients included in the study, 223 (45.2%) were aged > or = 65 years, and 265 (53.7%) had one or more underlying diseases, mostly chronic obstructive pulmonary disease, diabetes mellitus or dementia. In total, 281 microorganisms were identified in 250 (50.7%) patients, with two or more pathogens detected in 28 (5.7%) cases. Microbial diagnosis varied according to age, severity, co-morbidity and site-of-care, but there was much overlap among groups. Streptococcus pneumoniae was the single most prevalent organism in outpatients, patients admitted to hospital, and patients who died, either as a single pathogen or combined with another organism. Infections caused by 'atypical' pathogens were seen across all groups, including the elderly and patients with co-morbidities. Mortality varied according to the pneumonia severity index (PSI) of the pneumonia patient outcomes research team. Shock (OR 34.48), an age of > 65 years (OR 25) and altered mental status (OR 9.92) were factors associated independently with 30-day mortality. Key findings from this study were the advanced age of the population with CAP, and the high prevalence of dementia as an underlying disease. The study also revealed that microbiological diagnosis of CAP remains problematic. Although certain epidemiological features may help to predict the microbial aetiology, the overlap among groups reduces the usefulness of this information in guiding therapeutic decisions. Greater effort should be made to improve identification methods for microbial pathogens causing CAP.

What Causes Increased Stroke Mortality in Patients with Prestroke Dementia?

BACKGROUND AND PURPOSE

In patients with dementia, the incidence of stroke is higher and strokes are more severe and lethal. The purpose of this population-based study was to describe in what way previous dementia affects mortality in stroke patients.

METHODS

Subjects were all persons > or =65 years old who had a first-ever stroke during 1 year (n = 327). The prestroke dementia (PSD) diagnosis was made at the time of the stroke diagnosis using data from next of kin and from patient records. Patients were followed prospectively and causes of death were evaluated.

RESULTS

The 28-day case fatality was 44% for PSD patients and 15% for non-PSD patients. Corresponding ratios at 1 year were 71 and 36%, respectively. Twenty-eight percent of the PSD patients had a new stroke during the first year, compared to 8% of the non-PSD patients. More patients in the PSD group died as a direct or indirect consequence of their stroke. Multivariate analysis showed that PSD, in addition to age, atrial fibrillation and stroke severity, was an independent predictor of mortality.

CONCLUSIONS

The PSD patients more often had a stroke-related death, even when we adjusted for a number of other factors. The cause for this is most likely multifactorial, including an increased tendency to contract complications in the acute phase, and iatrogenic causes. The brain of the PSD patients may also be frailer and more susceptible to ischemic or hemorrhagic damage than the nondemented brain.

Anaesthesia in patients with dementia

PURPOSE OF REVIEW

The next couple of decades will be characterized by an increase in life expectancy, leading to an older population. As the incidence of Alzheimer's dementia and vascular dementia is rising with age, the future anaesthesiologist will be increasingly confronted with perioperative care of patients with impaired cognitive function. This paper tries to highlight some topics specifically related to demented patients.

RECENT FINDINGS

Psychometric testing and behaviour vary according to the type of dementia. Neuroanatomical and biochemical correlates for different types of dementia are more precise and better documented. Evidence exists that cognition may be impaired for weeks after anaesthesia, but the mental capacities of those who have undergone surgery are comparable to those of age controls in the long term. Most research efforts are focused on improving the daily functioning of people with cognitive impairment. Several new anticholinesterases are being evaluated. It is advantageous to keep cognition optimal throughout the perioperative period. Neuroleptics may be badly tolerated and, most importantly, pain pathways may be differentially affected in dementia.

SUMMARY

Anaesthesia in the demented patient may be complicated by a number of potential problems, including the comorbid pathology, the concomitant anticholinesterase activity, the need for normoventilation, monitoring of anaesthesia depth and the evaluation of postoperative pain. Anaesthesia in variant Creutzfeldt-Jakob disease is aimed at preventing the spread of the causing prion. There is a broad consensus that early return to the preoperative level of cognition is to be pursued, with the help of short-acting drugs and loco-regional anaesthesia.