The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia

Behavioral disorders in Parkinson disease: current view

Patients with Parkinson disease (PD) frequently experience several behavioral symptoms, such as anxiety, apathy, irritability, agitation, impulsive control and obsessive-compulsive or REM sleep behavior disorders, which can cause severe psychosocial problems and impair quality of life. Occurring in 30-70% of PD patients, these symptoms can manifest at early stages of the disease, sometimes even before the appearance of classic motor symptoms, while others can develop later. Behavioral changes in PD show distinct patterns of brain atrophy, dopaminergic and serotonergic deterioration, altered neuronal connectivity in frontostriatal, corticolimbic, default mode and other networks due to a cascade linking molecular pathologies and deficits in multiple behavior domains. The changes suggest a multi-system neurodegenerative process in the context of a specific α-synucleinopathy inducing a variety of biochemical and functional changes, the neurobiological basis and clinical relevance of which await further elucidation. This paper is intended to review the recent literature with focus on the main behavioral disturbances in PD patients, their epidemiology, clinical features, risk factors, animal models, neuroimaging findings, pathophysiological backgrounds, and treatment options of these deleterious lesions.

Cognitive behavioural treatment for mild Alzheimer's patients and their caregivers (CBTAC): results of a randomised controlled trial

OBJECTIVES

This study aimed to evaluate the effects of a multicomponent psychotherapy programme for people with mild Alzheimer's dementia (AD) and their caregivers on depression and related neuropsychiatric symptoms.

METHOD

The cognitive behavioural therapy (CBT)-based treatment consisted of 25 weekly sessions, including behavioural activation, behaviour management, interventions for the caregiver, reminiscence, couples counselling, and cognitive restructuring. 41 participants and their caregivers were randomised to either the CBT or the control group, which received treatment-as-usual (TAU). Follow-ups took place at 6 and 12 months posttreatment. The primary outcome was depression in the patient with AD. The secondary outcomes were apathy, other neuropsychiatric symptoms, functional abilities, quality of life, and quality of the relationship with the caregiver.

RESULTS

Linear mixed models revealed a statistically significant superiority of CBT regarding clinician-rated depression at the 12-month follow-up with large effect sizes (within-subject d = 1.22, between-subject d = 1.00). Effect sizes were only moderate for self-rated depression and small for informant-rated depression. There was also a significant advantage for CBT regarding clinician-rated apathy, relationship quality, and informant-rated quality of life (QoL) but not for the other neuropsychiatric symptoms or self-rated QoL.

CONCLUSION

The results are very encouraging and support an adequately powered multicentre study.

Trial registration: ClinicalTrials.gov NCT01273272. Date of registration: 3 Jan 2011.

Parallel changes in cognition, neuropsychiatric symptoms, and amyloid in cognitively unimpaired older adults and those with mild cognitive impairment

INTRODUCTION

Alzheimer's disease (AD) diagnosis centers on cognitive impairment despite other early indicators like neuropsychiatric symptoms (NPSs) and amyloid beta (Aβ) accumulation. This study examined how cognition, NPS, and Aβ changes are interrelated over time in individuals without dementia.

METHODS

Participants were 1247 individuals from the Alzheimer's Disease Neuroimaging Initiative (ADNI)-2 and -3 cohorts with at least 48 months of follow-up. Cognitive domains were assessed via ADNI composite measures, NPS via the neuropsychiatric inventory, and Aβ via standardized uptake value ratio (SUVR) composite scores. Co-occurring changes were evaluated with parallel process models.

RESULTS

NPS was longitudinally associated with performance in each cognitive domain. Negative baseline Aβ-cognition associations were observed in three cognitive domains. No Aβ-NPS associations were observed.

DISCUSSION

This study demonstrated strong longitudinal relationships between NPS and cognition in preclinical and prodromal stages of AD. Future studies should incorporate NPS into models of disease trajectories to improve early detection and prediction of disease progression.

HIGHLIGHTS

Co-occurring changes in Aβ, cognition, and neuropsychiatric symptoms are understudied. We found relationships between neuropsychiatric symptoms and cognition. We found baseline, but not longitudinal, Aβ and cognition associations. Changes in neuropsychiatric symptoms should be included in early detection models of ADRD.

Music moves: Ettlingen dementia study - a pragmatic randomised controlled trial

OBJECTIVES

Due to the limited effectiveness of pharmacological treatment, there is a growing need to explore non-pharmacological psychosocial interventions such as music therapy when treating the behavioural and psychological symptoms of dementia (BPSD).

METHOD

We randomised 57 nursing home residents into individual active music therapy plus standard care (aMT), individual receptive music therapy with tactile sound vibration plus standard care (rMT), or the standard care control group (CG). A trained music therapist provided 12 sessions over 6 weeks. The outcomes (BPSD; depression; quality of life; medical system usage; activities of daily living; music therapy engagement) were measured at baseline (0 week), post-intervention (6 weeks), and follow-up (12 weeks).

RESULTS

The results indicated small beneficial effects for BPSD in aMT and rMT at follow-up, a small beneficial effect for total musical engagement in aMT and rMT, a small negative effect for verbal communication in rMT, and a small beneficial effect for medical usage in the CG.

CONCLUSION

Both aMT and rMT methods showed promise for managing BPSD and increasing engagement during music therapy. rMT may be more suited for advanced stages of dementia. Future studies should evaluate the appropriateness and effectiveness of each intervention according to disease severity.

The effect of the APOE4 genotype on physiological and cognitive health in randomised controlled trials with an exercise intervention: a systematic review and meta-analysis

BACKGROUND

Alzheimer's disease is caused by modifiable and non-modifiable risk factors. Randomised controlled trials have investigated whether the strongest genetic risk factor for Alzheimer's disease, APOE4, impacts the effectiveness of exercise on health. Systematic reviews are yet to evaluate the effect of exercise on physical and cognitive outcomes in APOE genotyped participants. A quality assessment of these randomised controlled trials is needed to understand the impact genotype has on the potential success of intervention. This systematic review aimed to determine if the APOE4 genotype influences the effectiveness of exercise-based randomised controlled trials.

METHOD

Searches on MEDLINE, EMBASE, and PsycINFO identified eligible exercise based randomised controlled trials incorporating participants with varied cognitive abilities. Quality assessments were conducted.

RESULTS

Nineteen studies met the inclusion criteria for systematic review, and 3 for the meta-analysis. Very low to moderate quality evidence showed that APOE4 carriers benefitted more than APOE4 non-carriers on cognitive (e.g. executive function, learning) and physical (e.g. relative telomere length) outcomes after exercise; and that APOE4 non-carriers benefited over carriers for physical (serum BDNF, gait speed) and cognitive (global cognition, verbal memory) markers. Very low quality evidence indicated that there was no evidence of difference between APOE4 carriers and non-carriers on physical function outcomes in meta-analysis. Several areas of study design and reporting, including maintenance of relative exercise intensity and complete statistical reporting, were identified as needing improvement.

DISCUSSION

This systematic review found very limited evidence to suggest that exercise interventions can benefit APOE4 carriers and non-carriers equally, though conclusions were limited by evidence quality. Further randomised controlled trials, stratifying participants by APOE status are required to better understand the relationship between APOE genotype and the effect of exercise on health-related outcomes.

TRIAL REGISTRATION

This review was registered with PROSPERO (CRD42023436842). Registered on June 16, 2023.

Prevalence of delirium in German nursing homes: protocol for a cross-sectional study

INTRODUCTION

Delirium is a neuropathological syndrome that is associated with several negative outcomes. Nursing home residents are vulnerable to developing delirium. Valid prevalence data and associated factors are not yet available for Germany. Therefore, the aim of the prevalence study of the DeliA project (Delirium in Nursing Homes) is to assess the prevalence of delirium and its associated factors in 750 nursing home residents.

METHODS AND ANALYSIS

Trained registered nurses from each participating nursing home will collect the data in a multicentre cross-sectional study. The inclusion criteria for residents are valid informed consent, age ≥65 years and sufficient language skills. The exclusion criteria are aphasia, coma, deafness or end-of-life status. The 4 'A's Test will be used as the primary measurement. Delirium motor subtypes will be determined using the Delirium Motor Subtype Scale. Covariables for associated factors, including functional impairments, pain, cognitive status and nutritional status, are assessed through standardised measurements. Moreover, data such as prescribed drugs or medical diagnosis, hearing impairment or falls will be assessed from the nursing records. Furthermore, the Drug Burden Index will be calculated, and associated factors will be determined using a logistic regression model. The period for data collection in participating nursing homes is planned for 2 consecutive weeks in April 2024.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Witten/Herdecke University (no. 82/2023). Findings will be published in peer-reviewed journals and presented at conferences.

REGISTRATION

https://osf.io/xkfvh/ (DOI 10.17605/OSF.IO/XKFVH).

Examining Specific Theory-of-Mind Aspects in Amnestic and Non-Amnestic Mild Cognitive Impairment: Their Relationships with Sleep Duration and Cognitive Planning

Background/Objectives: The study examined the relationships between specific Theory-of-Mind (ToM) dimensions, cognitive planning, and sleep duration in aging adults. Methods: The sample included 179 participants, comprising 46 cognitively healthy individuals, 75 diagnosed with amnestic Mild Cognitive Impairment (aMCI), and 58 with non-amnestic (naMCI). The mean age of the participants was 70.23 years (SD = 4.74), with a mean educational attainment of 12.35 years (SD = 3.22) and gender distribution of 53 men and 126 women. ToM assessment included tasks measuring the understanding and interpretation of non-literal speech, proverbs and metaphors, as well as an emotion-recognition test. For cognitive planning, a Tower Test was utilized. Sleep duration was measured using actigraphy. Results: We identified significant differences in various ToM tasks' performance between the groups, particularly in non-literal speech tasks and third-order ToM stories. The HC group consistently outperformed both MCI groups in these tasks, with aMCI showing higher performance than naMCI. Mediation analysis applied to examine potential direct and indirect effects of sleep duration on ToM tasks indicated that total sleep time had significant indirect effects through cognitive planning-mainly as rule violation total score-on specific ToM aspects. Hence, besides the effects of MCI pathologies and especially of naMCI, sleep duration seems also to be associated with ToM performance in aging via specific executive functioning decrements. Conclusions: The findings underscore the social implications of ToM deficits due to MCI and/or sleep duration decrease, particularly in naMCI older adults, as they can seriously impair their social interactions. Targeted interventions could improve emotional understanding, communication, and overall quality of life.

Longitudinal study of care needs and behavioural changes in people living with dementia using in-home assessment data

BACKGROUND

People living with dementia often experience changes in independence and daily living, affecting their well-being and quality of life. Behavioural changes correlate with cognitive decline, functional impairment, caregiver distress, and care availability.

METHODS

We use data from a 3-year prospective observational study of 141 people with dementia at home, using the Bristol Activities of Daily Living Scale, Neuropsychiatric Inventory and cognitive assessments, alongside self-reported and healthcare-related data.

RESULTS

Here we show, psychiatric behavioural symptoms and difficulties in activities of daily living, fluctuate alongside cognitive decline. 677 activities of daily living and 632 psychiatric behaviour questionnaires are available at intervals of 3 months. Clustering shows three severity-based groups. Mild cognitive decline associates with higher caregiver anxiety, while the most severe group interacts more with community services, but less with hospitals.

CONCLUSIONS

We characterise behavioural symptoms and difficulties in activities of daily living in dementia, offering clinically relevant insights not commonly considered in current practice. We provide a holistic overview of participants' health during their progression of dementia.

Caregiving Satisfaction, Psychological Distress and Caregiver Burden in Family Caregivers of Dependent Older People: A Longitudinal Study

BACKGROUND AND OBJECTIVES

Although a substantial amount of research has focused on negative aspects of caregiving, less research has been conducted investigating positive aspects of providing informal care. The aim of this study was to investigate the longitudinal association between caregiving satisfaction and psychological distress in informal carers of dependent older people, and whether this relationship is mediated by caregiver burden.

RESEARCH DESIGN AND METHODS

Prospective longitudinal study with a probabilistic sample of 332 caregivers of older relatives, with data collected at baseline and at 1-year follow-up. We measured caregiving satisfaction, psychological distress, subjective caregiver burden and several covariates (caregivers' sex, age and objective caregiver burden). Data were analysed using generalised estimation equations with multiple imputation. The STROBE checklist was used to support the writing of this document.

RESULTS

After controlling for covariates, caregiving satisfaction was significantly negatively associated with lower levels of subjective caregiver burden (B = -0.17, 95% CI: -0.23, -0.11) and emotional distress (B = -0.23, 95% CI: -0.36, -0.11). When subjective burden was included in the model, the relationship between caregiving satisfaction and psychological distress was no longer significant (B = -0.11, 95% CI: -0.23, 0.02), whereas the association between subjective burden and psychological distress remained (B = 0.75, 95% CI: 0.57, 0.92). The Sobel test confirmed these results (p < 0.001), indicating that subjective caregiver burden mediates the relationship between caregiving satisfaction and psychological distress (complete mediation) over time.

DISCUSSION AND IMPLICATIONS

Caregiving satisfaction exerts a longitudinal protective effect on carers' psychological distress via subjective burden. Our findings indicate that interventions aimed at strengthening caregiving satisfaction may play a significant role in maintaining positive mental health outcomes for informal caregivers.

Association between self-reported and proxy informant Health Quality of life of older adults with the use of antipsychotic drugs in nursing homes. A cross-sectional study

INTRODUCTION

Antipsychotic prescriptions are frequent in nursing homes due to the challenging management of symptoms associated with Alzheimer's disease and related neurodegenerative disorders. This study aimed to assess the association between Health-related Quality Of Life (HrQOL) and antipsychotic use in nursing homes.

METHODS

This is a cross-sectional study of the KASEHPAD (Karukera Study of Ageing in Nursing Homes) study conducted in six nursing homes in Guadeloupe and Martinique (French West Indies). The EuroQol 5-dimensional questionnaire (EQ-5D) was used to measure HRQoL. Clinical characteristics and use of antipsychotic drugs of 194 older adults with both self-reported and proxy informant HrQOL index were extracted. Other outcomes measures included the frequency and severity of delusions, hallucinations and agitation using the reduced Neuropsychiatric Inventory Nursing Home (NPI-R) score, Activities of Daily Living (ADL) score and Mini-Mental State Examination (MMSE) score.

RESULTS

The mean age of participants was 81.3 years and 63.6% had major cognitive impairment (MMSE score ≤18). The prevalence of delusions (39.7%), hallucinations (27.8%) and agitation (40.7%) was high. Antipsychotic medication was prescribed to 37.1% of the participants. The self-reported HrQOL Index of older adults was higher than the proxy HrQOL Index (0.54 ± 0.43 versus 0.40 ± 0.43) with a correlation coefficient of 0.63 (p<0.001). The use of antipsychotic medication was associated with a higher self-reported HrQOL index, after controlling for the frequency (β = 0.144, p = 0.024) or severity (β = 0.159, p = 0.009) of delusions, hallucinations and agitation symptoms. Conversely, antipsychotic use was not associated with proxy HrQOL Index.

CONCLUSION

Despite the adverse effects of long-term use of antipsychotic drugs in older adults, it is associated with better-perceived HrQOL among nursing home residents. However, this association was not observed when HrQOL was assessed by proxy informants. This finding may explain the challenges in reducing the use of this therapeutic class in nursing homes.

Behavioural and psychological symptoms of people with dementia in acute hospital settings: a systematic review and meta-analysis

BACKGROUND

Behavioural and psychological symptoms of dementia (BPSD) can complicate acute hospital care, but evidence on BPSD in this setting is heterogeneous.

OBJECTIVE

To determine the prevalence of BPSD in acute hospitals and explore related risk factors, treatments, and outcomes (PROSPERO: CRD42023406294).

METHODS

We conducted a systematic review and meta-analysis by searching Cochrane Library, MEDLINE, and PsycINFO for studies on BPSD prevalence among older people with dementia during their acute hospital admissions (up to 5 March 2024). Independent double-review processes were used for study screening, selection, and data extraction. Data on 12 BPSD symptoms were extracted based on the Neuropsychiatric Inventory Questionnaire (NPI) and Behavioural Pathology in Alzheimer's Disease (BEHAVE-ad). Risk factors, treatments, and outcomes were summarised. Meta-analysis was used to synthesise results.

RESULTS

Out of 15 101 records, 30 articles from 23 studies were included. Most studies were rated as moderate (n = 12) to poor (n = 17) quality. Meta-analysis revealed a pooled prevalence of overall BPSD (one or more BPSD symptoms) at 60% (95% CI = 43-78%) among older inpatients with dementia in acute hospitals (N = 11 studies). Subgroup analysis showed variations in the overall BPSD prevalence based on assessment tools (BEHAVE-ad = 85%, NPI = 74%, Others = 40%). Common BPSD symptoms included aggression/agitation (39%), sleep problems (38%), eating problems (36%), and irritability (32%). BPSD were linked to delirium, pain, increased use of uncomfortable interventions, psychotropic medication uses and higher caregiver distress. Poor patient-staff interactions and fragmented discharge plans often led to frequent emergency admissions and hospital readmissions.

CONCLUSION

Healthcare systems should implement tailored approaches for managing BPSD in acute hospitals, enhance staff training, improve caregiver communication, and develop integrated discharge plans.

Effectiveness of a psychoeducational program for caregivers of persons with acquired brain injury: a randomized controlled trial (EDUCA-V)

OBJECTIVE

To assess the effectiveness of a psychoeducational intervention program (PIP) compared to standard attention in reducing caregiver burden after the intervention (at 4 months) and at follow-up (at 8 months).

METHODS

A multicenter, evaluator-blind, randomized controlled trial. The experimental group received a PIP intervention consisting of 10 weekly group sessions, while the control group received standard attention. The primary outcome was measured as the change scores from baseline on the caregiver's burden (ZBI). The secondary outcomes evaluated included caregiver mental health (GHQ-28), anxiety (STAI), and depression (CES-D). Trial registration: ISRCTN16513116.

RESULTS

The sample comprised 76 informal caregivers (41 allocated in the intervention condition and 35 in the control). The caregiver's burden (ZBI) did not show significant differences between groups at 4 months or 8 months. There were favorable and significant changes in the caregiver's mental health (GHQ) and depression (CES-D) at 4 months in the PIP group. There were no significant differences between groups in anxiety during the trial.

CONCLUSIONS

The PIP intervention group reported positive effects on general mental health and depression after the intervention but not at follow-up. We need more studies which interventions follow expert recommendations and can sustain positive results over time.

An international core outcome set for primary progressive aphasia (COS-PPA): Consensus-based recommendations for communication interventions across research and clinical settings

INTRODUCTION

Interventions to treat speech-language difficulties in primary progressive aphasia (PPA) often use word accuracy as a highly comparable outcome. However, there are more constructs of importance to people with PPA that have received less attention.

METHODS

Following Core Outcome Set Standards for Development Recommendations (COSSTAD), this study comprised: Stage 1 - systematic review to identify measures; Stage 2 - consensus groups to identify important outcome constructs for people with PPA (n = 82) and care partners (n = 91); Stage 3 - e-Delphi consensus with 57 researchers.

RESULTS

The systematic review identified 84 Outcome Measurement Instruments. Core outcome constructs identified included: (1) Participate in conversations with family and friends, (2) get words out, (3) be more fluent, (4) convey a message by any means, and (5) understand what others are saying. Researchers were unable to reach a consensus on measurement instruments.

DISCUSSION

Further work is required to develop appropriate measurement instruments that address all core outcome constructs important to key stakeholders.

HIGHLIGHTS

We introduce new symptom-led perspectives on primary progressive aphasia (PPA). The focus is on non-fluent/agrammatic (nfvPPA) and semantic (svPPA) variants. Foregrounding of early and non-verbal features of PPA and clinical trajectories is featured. We introduce a symptom-led staging scheme for PPA. We propose a prototype for a functional impairment scale, the PPA Progression Planning Aid.

Risk factors of male and female Alzheimer's disease patients with neuropsychiatric symptoms

BACKGROUND

This study investigates risk factors in the population of Alzheimer disease (AD) patients with NPS (ADNPS).

METHOD

Baseline risk factors associated with male and female ADNPS were examined using data from a regional AD care center. Univariate analysis was used to determine factors in male and female patients, while logistic regression models were developed to generate odds ratios (OR) to predict risk factors that are associated with male or female ADNPS.

RESULTS

In the adjusted analysis, dyslipidemia (OR = 0.630, 95 % CI, 0.431-0.992, P = 0.017), thyroid dysfunction (OR = 0.549, 95 % CI, 0.377-0.798, P = 0.002), and cerebral infarction (OR = 0.684, 95 % CI, 0.472-0.991, P = 0.0085) were associated with male ADNPS patients, whereas chronic heart failure (OR = 1.408, 95 % CI, 0.953-2.079, P = 0.0085) was associated with female ADNPS patients.

CONCLUSIONS

Our results reveal that female ADNPS patients were associated with heart failure, whereas male patients were associated with dyslipidemia and cerebral infarction.

Sleepiness, sleep time, and depression of caregivers are linked with sleep and behaviors of their paired partners with dementia

Background

Sleep difficulties in people with Alzheimer's disease (AD) and their caregivers (CGs) have been documented. Additionally, sleep disturbances are a risk for AD indicating that poor sleep in CGs may place them at risk for AD. Little is known about the relationship between sleep in people with dementia (PWD) and their CGs.

Objective

This pilot study examines sleep in PWD and CGs dyads, and the relationship between PWD sleep and CG sleep, cognition, and burden. We explore whether disordered sleep, degree of dementia and PWD behaviors are related to CG sleep difficulties and burden.

Methods

We examined sleep using overnight polysomnography (PSG) and day/night activity using 14-day actigraphy in PWD/CG dyads form the Virginia Alzheimer's Disease Center Clinical Cohort. Dyad members received the Montreal Cognitive Assessment (MoCA), behavioral and mood assessments. CGs completed CG burden and preparedness assessments.

Results

Mean activity from actigraphy did not differ within dyad members. PSG measurement of total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SEff), and wake after sleep onset (WASO) revealed that CGs had significantly decreased TST compared to their PWD and experienced greater SOL. Lower PWD MoCA scores were unrelated to CG sleep. However, PWD neuropsychiatric symptoms and CG burden correlated with worse CG SOL.

Conclusions

Our findings suggest that chronic rest and activity are linked within dyad members and that when separated, CGs experience shorter TST, lower SEff, and longer SOL than their partners. Additionally neuropsychiatric symptoms and CG burden were associated with worse CG sleep.

Association between meaningful activities and behavioural and psychological symptoms of dementia among people with early-onset dementia using long-term care services

BACKGROUND

The aim of this study was to clarify the engagement status of meaningful activities (MA) and its association with behavioural and psychological symptoms of dementia (BPSD) among people with early-onset dementia (EOD).

METHODS

This cross-sectional study included 367 facilities that provide long-term care insurance (LTCI) services in Sapporo, Japan. A questionnaire was sent to these facilities to determine whether they had ever cared for people with EOD who developed dementia before the age of 65 and used LTCI services. For facilities that had provided such care, the engagement status of MA for people with EOD was determined, along with the presence or absence of BPSD.

RESULTS

A total of 54 facilities had experience accepting people with EOD (14.7%), and the statuses of 69 people with EOD were determined following approval for providing information from these facilities. In total, 27 of the 69 people with EOD (39.1%) were engaged in MA. Multivariate-adjusted regression model revealed that the absence of apathy was significantly associated with the engagement status of MA after adjustment for age, sex, and dementia severity.

CONCLUSION

MA was performed by less than 40% of people with EOD using Japanese LTCI services, and it was negatively associated only with apathy among BPSD.

Glutathione S-transferase polymorphisms (GSTM1/GSTT1) outcomes in clinical profile and treatment responsiveness among Tunisian cohort of Parkinson's disease

Glutathione S-transferases are involved in the oxidative stress which contributes to the pathogenesis of Parkinson's disease (PD). our aim was to investigate the influence of GSTM1 and GSTT1 polymorphisms on the clinical features and treatments outcomes among PD Tunisian patients. We included 300-PD patients followed in neurology department at Razi-University-hospital. GSTM1 and GSTT1 were screened using PCR methods. Correlation between the clinical phenotype and the genotypes was then assessed after adequate parameters adjustment. Individuals carrying inactive GSTT1/GSTM1 were estimated to have 2.5-fold higher risk of developing PD, p = 0.035. The demographic and clinical baseline analysis of GSTM1 polymorphism revealed significant association between the inactive gene and development of tremor as first symptoms (p = 0.046), further, it was correlated to asymmetric start (p = 0.044). The evaluation of the impact of GSTM1/GSTT1 activity among PD at last follow-up revealed the significant variability of motor impairment among cases carrier of the active genes (p = 0.048). As patients with inactive GSTM1/GSTT1 had higher UPDRS-III score. Additionally, higher frequency of cases with good treatment responsiveness was reported among PD with active GSTM1/GSTT1 (p = 0.038).No motor complications were observed among PD by considering the GSTs genotypes (p > 0.05). Finally, we noted significant impairment of memory among cases with inactivate GSTs (p = 0.04), attention deficit (p = 0.013) and impaired judgement (p = 0.0031). This study represents one of the most comprehensive and extensive investigation to date regarding the influence of GSTT1/GSTM1 genotype among PD patients.We speculate that the impact of GSTT1/GSTM1 on PD progression may occur through a cumulative effect, potentially not manifesting during the initial PD stages. Further studies are necessary to validate our conclusions.

Protocol for a Survey on the Impact of Caring for a Relative With Dementia on Caregivers' Health and Work Functioning

With the increasing incidence of dementia in Japan due to an aging population and declining birthrate, supporting family caregivers is crucial. A survey was conducted at the hospital of the University of Occupational and Environmental Health, Japan from October 1, 2021, to February 29, 2024, involving dementia patients and their working caregiver relatives. The survey assessed health, living, work, caregiving status, sociodemographic factors, and the care recipient's condition. A total of 214 patient-caregiver pairs participated; consent was obtained from 212 pairs, and data were collected from 166 caregivers. The caregivers were predominantly women, with 54 (33%) male caregivers and a mean age of 54.7 years. Health status was reported as good (33%) or fair (50%); however, 46% experienced sleep disturbances, 44% had psychological distress, 18% reported work dysfunction, and 8% noted poor social adjustment. Most of the care recipients were women (65%), with a mean age of 79.8 years. The most common diagnoses were mild cognitive impairment (37%) and Alzheimer's disease (35%), with an average mini-mental state examination score of 21.6. This study outlines the survey protocol, focusing on the health, work, and caregiving conditions of working relatives caring for dementia patients.

The Alzheimer's Association clinical practice guideline for the diagnostic evaluation, testing, counseling, and disclosure of suspected Alzheimer's disease and related disorders (DETeCD-ADRD): Validated clinical assessment instruments

US clinical practice guidelines for the diagnostic evaluation of cognitive impairment due to Alzheimer's Disease (AD) or AD and related dementias (ADRD) are decades old and aimed at specialists. This evidence-based guideline was developed to empower all-including primary care-clinicians to implement a structured approach for evaluating a patient with symptoms that may represent clinical AD/ADRD. As part of the modified Delphi approach and guideline development process (7374 publications were reviewed; 133 met inclusion criteria) an expert workgroup developed recommendations as steps in a patient-centered evaluation process. The workgroup provided a summary of validated instruments to measure symptoms in daily life (including cognition, mood and behavior, and daily function) and to test for signs of cognitive impairment in the office. This article distills this information to provide a resource to support clinicians in the implementation of this approach in clinical practice. The companion articles provide context for primary care and specialty clinicians with regard to how to fit these instruments into the workflow and actions to take when integration of performance on these instruments with clinical profile and clinician judgment support potential cognitive impairment.

Informal care for people with dementia in Europe

INTRODUCTION

Informal care estimates for use in health-economic models are lacking. We aimed to estimate the association between informal care time and dementia symptoms across Europe.

METHODS

A secondary analysis was performed on 13,529 observations in 5,369 persons from 9 European pooled cohort or trial studies in community-dwelling persons with dementia. A mixed regression model was fitted to time spent on instrumental or basic activities of daily living using disease severity and demographic characteristics.

RESULTS

Daily informal care time was 0.5 hours higher in moderate compared to mild and 1.3h higher in severe compared to mild cognitive impairment. Likewise, this was 1.2h and 2.7h for functional disability and 0.3h and 0.6h for behavioral symptoms in the same directions.

DISCUSSION

Estimates can be used in both single- and multi-domain health-economic models for dementia in European settings.

Caregiver perspectives enable accurate diagnosis of neurodegenerative disease

BACKGROUND

The history from a relative or caregiver is an important tool for differentiating neurodegenerative disease. We characterized patterns of caregiver questionnaire responses, at diagnosis and follow-up, on the Cambridge Behavioural Inventory (CBI).

METHODS

Data-driven multivariate analysis (n = 4952 questionnaires) was undertaken for participants (n = 2481) with Alzheimer's disease (typical/amnestic n = 543, language n = 50, and posterior cortical n = 50 presentations), Parkinson's disease (n = 740), dementia with Lewy bodies (n = 55), multiple system atrophy (n = 55), progressive supranuclear palsy (n = 422), corticobasal syndrome (n = 176), behavioral variant frontotemporal dementia (n = 218), semantic (n = 125) and non-fluent variant progressive aphasia (n = 88), and motor neuron disease (n = 12).

RESULTS

Item-level support vector machine learning gave high diagnostic accuracy between diseases (area under the curve mean 0.83), despite transdiagnostic changes in memory, behavior, and everyday function. There was progression in CBI subscores over time, which varied by diagnosis.

DISCUSSION

Our results highlight the differential diagnostic information for a wide range of neurodegenerative diseases contained in a simple, structured collateral history.

HIGHLIGHTS

We analyzed 4952 questionnaires from caregivers of 2481 participants with neurodegenerative disease. Behavioral and neuropsychiatric manifestations of neurodegenerative disease had overlapping diagnostic boundaries. Simple questionnaire response patterns were sufficient for accurate diagnosis of each disease. We reinforce the value of a collateral history to support a diagnosis of dementia. The Cambridge Behavioural Inventory is sensitive to change over time and suitable as an outcome measure in clinical trials.

Neuropsychiatric and behavioral symptom clusters in frontotemporal dementia

Background

Non-Alzheimer's disease dementias, including frontotemporal dementia (FTD) can be difficult to characterize due to the predominance of distinct behavioral and neuropsychiatric symptoms. Widely used measurement tools lack structure and objectivity.

Objective

The purpose of this study was to use systematic direct observation of neuropsychiatric and behavioral symptoms, via the Neurobehavioral Rating Scale (NBRS), to characterize clusters of behavioral and neuropsychiatric symptoms in FTD and examine how selected symptom clusters correlate with structural neuroimaging.

Methods

We performed a factor analysis on the NBRS data from 172 patients with FTD and examined the neural correlates of the selected symptom clusters in a subsample of 67 patients.

Results

Six factors accounted for 56% of total variance across NBRS item scores: Apathy/Blunting, Agitation/Disinhibition, Cognitive/Language, Planning/Insight, Anxiety/Lability, and Psychosis. Symptom clusters showed significant associations with specific regions of cortical thinning: Agitation/Disinhibition with bilateral frontal regions, and Cognition/Language with the left bank of the superior temporal sulcus and supramarginal regions.

Conclusions

The selected symptom clusters associated with known regions of atrophy in FTD. The NBRS is an effective observational measure that may extend characterization and understanding of FTD.

Preventing risk of placement breakdown and hospital admission in the management of distressed behaviour in dementia care: A qualitative case study with family and care-home staff

Objectives: Behaviours such as hitting-out and declining personal care are commonly exhibited by people living with dementia and are associated with care-giver stress and anxiety and care home placement breakdowns. Traditionally, pharmacological approaches have been used to manage behaviour; however, research indicates limited effectiveness. National guidelines recommend use of non-pharmacological interventions as first line treatment for distress, but further research is required to elucidate the components that lead to improved care for people living with dementia. This study aims to explore what works, examining case studies in which a non-pharmacological clinical intervention, the Newcastle Model, was used to understand and manage distressed behaviour in dementia care within care home settings. Method: A qualitative case study design was used. Three cases were selected from the Edinburgh Behaviour Support Service for their success in preventing care home placement breakdown during a distressed behaviour intervention in NHS Scotland. Family members and staff involved in the interventions within these cases were interviewed (N = 6). Thematic analysis was used to analyse data. Findings: All participants reported positive outcomes from the intervention. Three key themes were identified, each with subthemes. Participants described a supportive, non-judgmental environment which allowed them to integrate knowledge about dementia and tailor interventions to the specific needs of the individual living with dementia. There was also a sense of family and staff coming together to unite with shared goals. A preliminary model of all of themes and their interactions is presented. Conclusion: The study supports use of biopsychosocial, formulation-led approaches in the understanding and treatment of complex behavioural presentations in community care settings. It suggests that clinicians should endeavour to facilitate safe and open environments for care home staff and family members, in order to promote attribution change and person-centered care, and to help mediate differences and conflict between staff and family members.

Delirium-like symptomatology in community-dwelling older adults with dementia

BACKGROUND

Delirium, a sudden and acute state of confusion, is known to be more prevalent in hospitalised older adults with dementia and is associated with lower levels of functioning after the delirium episode; yet, the literature on estimates of delirium prevalence in community-dwelling older adults with dementia is scarce. The aim of this study was to define and determine the frequency of delirium-like symptoms in two different samples of community-dwelling persons living with dementia, as reported by their family caregivers. 'Delirium-like symptoms' is a concept that specifies an occurrence of cognitive and behavioural symptoms, provoking suspicion of delirium, that represent a sudden and unusual deleterious change in a community-dwelling person living with dementia that can be identified by family caregivers and prompt healthcare seeking behaviours.

METHODS

The frequencies of delirium-like symptoms were assessed from two intensive longitudinal 21-day diary studies. Caregivers reported on presence of sudden and unusual cognition and behaviours each day. Descriptive statistics were used to determine the number of caregivers who reported delirium-like symptoms.

RESULTS

Family caregivers (n = 50, n = 102) were predominately non-Hispanic White (75%, 61%), female (94%, 85%), and a child (60%, 59%) of the care-recipient and completed 1389 and 1739 diaries from the first and second study respectively. Caregivers reported delirium-like symptoms for 12 (24%) and 27 (27%) of care-recipients.

CONCLUSION

Other studies of delirium in community-dwelling persons living with dementia have reported similar rates. More research is needed to understand the dynamic context of delirium in community settings to improve the care provided to them by their family caregivers and clinicians in services such as home, primary, and specialty healthcare.

Modulating effects of fitness and physical activity on Alzheimer's disease: Implications from a six-month randomized controlled sports intervention

BACKGROUND

Physical activity and fitness are major targets in Alzheimer's disease (AD) preventive research. However, current research is heterogeneous and often disregards the relationship between these parameters and disease outcomes.

OBJECTIVE

To assess the effects of physical activity and fitness on AD within the context of a multicomponent sports intervention.

METHODS

46 participants with early-stage AD (mean age 70 ± 7 years, 18 women, mean Montreal Cognitive Assessment (MoCA) score 19±5) were included in a six-month randomized controlled trial (Dementia-MOVE), participating in either a multicomponent sports intervention or a control condition with a psychoeducational program. The modulating effect of fitness and physical activity changes on AD outcome parameters such as cognition, function and cerebral brain structure from 3T-MRI were examined using multiple linear regression analyses.

RESULTS

An increase in VO2max was associated with assignment to the intervention group (p = 0.016), lower baseline fitness (p = 0.001), and an increased rate of physical activity (p = 0.046). Only in the intervention group, ΔVO2max had a beneficial modulating effect on the MoCA score (p = 0.039), the executive functions (p = 0.017) and regional brain volumes of the temporal lobe, e.g., the hippocampus (p = 0.044). High daily step count was associated with preserved executive functions (p = 0.001), and caregivers' quality of life (p ≤ 0.001) in the overall sample.

CONCLUSIONS

Our results confirm that multicomponent exercise improves cardiorespiratory fitness in AD, which is associated with advantageous developments in cognitive performance and preservation of brain structure. These findings suggest that especially patients with comparably worse cognition and fitness benefit and should be encouraged for activity engagement.

Prion diseases motor and neuropsychiatric symptom cluster pharmacotherapy: structured scoping review

BACKGROUND

Prion diseases are a group of rare, neurodegenerative conditions that are invariably fatal and cause a variety of symptoms, which can prove challenging to control. Through this paper, we aim to review the current evidence regarding pharmacological management of neuropsychiatric and motor symptoms of prion disease as well as draw on experts' and relatives' experience, to evaluate the current evidence and provide recommendations moving forwards.

METHODS

A scoping review of the literature for pharmacological management of symptoms was conducted using the systematic review tool, COVIDENCE, with searches conducted through four databases. 120 papers were selected for inclusion, and data extraction was carried out by two independent reviewers. Given the lack of high-quality data and small numbers, no further attempt at statistical analysis was made, and results are presented in a thematic synthesis.

RESULTS

Although a broad range of approaches and pharmacotherapies are trialled to manage these challenging symptoms, there are patterns emerging of some efficacy seen with the use of benzodiazepines, antipsychotic and anticonvulsant medications in both motor and neuropsychiatric symptoms in prion disease. These approaches and associated challenges were reflected in international expert opinion that was gathered via online survey.

CONCLUSION

There continues to be a paucity of good-quality evidence and we suggest a need for longitudinal, population-based and standardised research to allow a robust evidence base, which in turn will guide excellent symptom control and end of life care for this group of complex patients.

Utility of Tau PET in the diagnostic work up of neurodegenerative dementia among Indian patients

BACKGROUND AND OBJECTIVES

Tau PET is being increasingly appraised as a novel diagnostic modality for dementia work up. Given limited data among South Asians, we assessed the frequency, patterns, phenotypic associations and incremental value of positive Tau PET scans in clinically diagnosed neurodegenerative dementia.

METHODS

This cross-sectional study recruited consecutive patients of Alzheimer's disease (AD) and non-AD syndromes (September 2021 to October 2022, India). Participants underwent clinical interview, cognitive assessment, MRI brain and tau PET scan ([F-18]ML-104). Visual read in a priori regions of interest was used to identify patterns of tau deposition in the brain.

RESULTS

We recruited 54 participants (mean age: 63.2 ± 9.2 years, 64.8 % men, 77.8 % dementia, 70.4 % early onset cases, 37.8 % APOE4+). The analysis identified abnormal tau uptake in 40/54 (74.1 %) participants; with uptake in AD signature areas in 27/40 (67.5 %) cases [cortical subtype (74.1 %), limbic (14.8 %), combined cortical/limbic (11.1 %)], and patterns not conforming to AD in 13/40 (32.5 %) cases. Tau PET substantiated the diagnosis of AD among 17/19 (89.5 %) cases with clinically diagnosed AD dementia, 8/23 (34.8 %) cases with suspected non-AD cause, and 2/12 (16.7 %) cases with mild cognitive impairment. A trend for increasing proportion of early onset cases, and worsening cognition, behavior and functional ability was seen, from 'limbic' to 'combined cortical/limbic' to 'cortical' subgroups.

CONCLUSION

Tau PET is a useful modality to differentiate AD dementia from other neurodegenerative causes in the Indian setting where amyloid biomarkers are not widely available. Biological subtypes of AD map well onto clinical phenotypes and need study in larger cohorts.

Irritability in stroke: a protocol for a prospective study

Background

Poststroke irritability (PSI) is common among stroke survivors and can lead to a poor quality of life, difficulties in social interactions, criticism from caregivers, and caregiver stress. The planned study will evaluate the clinical, neuropsychological, and magnetic resonance imaging (MRI) correlates of PSI in a cohort of stroke survivors. In addition, the study will examine the 15-month progression of PSI.

Methods

This will be a prospective cohort study that will recruit 285 participants. Participants and their caregivers will undergo detailed assessments at a research clinic at 3, 9, and 15 months after stroke onset (T1/T2/T3). The irritability/lability subscale of the Chinese version of the Neuropsychiatric Inventory (CNPI) will be completed by caregivers. Potential covariates will also be measured. Patients will undergo MRI, including diffusion-weighted imaging, within 1 week of stroke onset. A stepwise logistic regression will be performed to evaluate the importance of lesions in the regions of interest (ROIs) along with other significant variables identified in univariate analyses. These analyses will be repeated for patients with and without PSI at T2 and T3. Repeated measures analysis of covariance (ANCOVA) will be used to assess changes in CNPI scores for the entire sample. In ANCOVA analyses, the frequency of infarcts in the ROIs will be treated as the predictor.

Discussion

This will be the first MRI study on PSI in stroke survivors. The findings will provide insights into the association of the orbitofrontal cortex, anterior cingulate cortex, anterior temporal lobe, insula, amygdala, thalamus, and basal ganglia lesions with the risk of PSI.

Multicenter Evaluation of Memory Remediation in Traumatic Brain Injury With Donepezil: A Randomized Controlled Trial

Memory impairments are common chronic and functionally important consequences of traumatic brain injury (TBI). Among patients with persistent verbal memory impairments due to TBI-related cholinergic deficits, donepezil (an acetylcholinesterase inhibitor) may improve these and related problems. The Multicenter Evaluation of Memory Remediation in TBI with Donepezil (MEMRI-TBI-D) study, a four-site, randomized, parallel-group, double-blind, placebo-controlled, 10-week clinical trial, evaluated the efficacy of donepezil on verbal memory impairments, co-occurring cognitive and noncognitive neuropsychiatric problems, and functional status among persons with severe, persistent, and functionally limiting verbal memory problems at least 6 months after mild, moderate, or severe TBI. Efficacy, safety, and tolerability measures were assessed. Seventy-five participants were randomly assigned to donepezil (N=37) and placebo (N=38) groups. In both modified intent-to-treat and per-protocol analyses, donepezil significantly improved memory (i.e., verbal learning, as measured by the Hopkins Verbal Learning Test-Revised Total Trials 1-3, the primary outcome measure) when compared with placebo. Treatment-responder rates in the donepezil and placebo groups were 42% and 18%, respectively, yielding a number needed to treat of 3.5. Among donepezil responders, delayed recall and processing speed also improved significantly. Treatment-emergent adverse event rates for donepezil and placebo were 46% and 8%, respectively, and mild or moderate (85%); diarrhea and nausea were significantly more common in the donepezil group, yielding a number needed to harm of 6.25 and a likelihood to be helped or harmed ratio of 1.79. These results suggest that donepezil is an efficacious treatment for severe, persistent memory impairments after predominantly severe TBI, with a relatively favorable safety and tolerability profile.

Neuropsychiatric Symptom Profile in Alzheimer's Disease and Their Relationship With Functional Decline

OBJECTIVE

Understanding the course of individual neuropsychiatric symptoms (NPS) and their relationship with function is important for planning targeted interventions for preventing and delaying functional decline. This study aims to disentangle relative contributions of individual NPS on functional decline.

METHODS

Longitudinal study of 9,358 well-characterized participants with baseline diagnoses of Mild Cognitive Impairment or AD in the National Alzheimer's Coordinating Center Uniform Data Set. Function was measured using the Functional Assessment Questionnaire (FAQ). Clinician judgment of seven common behavioral symptoms were examined simultaneously: apathy-withdrawal, depressed mood, visual or auditory hallucinations, delusions, disinhibition, irritability, and agitation.

RESULTS

Apathy was the most common NPS at baseline (33.7%) and throughout follow-up, endorsed by clinicians in 63.7% of visits. Apathy was the most persistent with 36.7% of participants having clinician-endorsed apathy in ≥50% of their visits. Apathy strongly correlated with faster rate of functional decline. Compared to those who never had apathy, baseline FAQ was worse in those with intermittent or persistent/always apathy (intermittent: estimated coefficient ±SE=1.228±0.210, 95% CI=[0.817, 1.639]; persistent/always: 2.354±0.244 (95% CI=[1.876, 2.832], both p <0.001). Over time, rate of functional decline was faster in those with intermittent and persistent/always apathy (intermittent: 0.454±0.091, 95% CI=[0.276, 0.632]; persistent/always: 0.635±0.102, 95% CI=[0.436, 0.835], both p <0.001). Worse agitation, delusions, and hallucinations also correlated with functional decline, but magnitudes of the estimates were smaller.

CONCLUSION

Individual NPS may be sensitive targets for tracking longitudinal change in function. The study raises awareness of the need for more comprehensive assessment of functional decline in AD patients with noncognitive symptoms.

Clinical characteristics of early-onset versus late-onset Alzheimer's disease: a systematic review and meta-analysis

OBJECTIVES

A number of studies have compared Alzheimer's disease (AD), the commonest form of dementia, based on their age of onset, i.e. before the age of 65 years (early-onset AD, EO-AD) to those developing after 65 years of age (late-onset AD, LO-AD), but the differences are not clear. We performed a systematic review and meta-analysis to compare clinical characteristics between EO-AD and LO-AD.

DESIGN, MEASUREMENTS, AND PARTICIPANTS

Medline, Embase, PsycINFO, and CINAHL databases were systematically searched for studies comparing time to diagnosis, cognitive scores, annual cognitive decline, activities of daily living (ADLs), neuropsychiatric symptoms (NPS), quality of life (QoL), and survival time for EO-AD and LO-AD patients.

RESULTS

Forty-two studies were included (EO-AD participants n = 5,544; LO-AD participants n = 16,042). An inverse variance method with random effects models was used to calculate overall effect estimates for each outcome. People with EO-AD had significantly poorer baseline cognitive performance and faster cognitive decline but longer survival times than people with LO-AD. There was no evidence that EO-AD patients differ from people with LO-AD in terms of symptom onset to diagnosis time, ADLs, and NPS. There were insufficient data to estimate overall effects of differences in QoL in EO-AD compared to LO-AD.

CONCLUSIONS

Our findings suggest that EO-AD differs from LO-AD in baseline cognition, cognitive decline, and survival time but otherwise has similar clinical characteristics to LO-AD. Larger studies using standardized questionnaires focusing on the clinical presentations are needed to better understand the impact of age of onset in AD.

Treatment of Alzheimer Disease

OBJECTIVE

Symptom-oriented treatment has been the mainstay of Alzheimer disease (AD) pharmacotherapy for decades. This article reviews the evidence basis for symptomatic treatments for AD and the emerging data on amyloid-lowering therapies with possible disease-slowing effects.

LATEST DEVELOPMENT

Amyloid-lowering monoclonal antibody therapies entered clinical use in 2021. In July 2023, lecanemab became the first of these to gain full US Food and Drug Administration (FDA) approval and limited Medicare payment coverage. Donanemab gained similar approval status in July 2024. The approved agents remove amyloid plaque from the brain and appear to slow clinical disease progression but can produce significant adverse events known as amyloid-related imaging abnormalities with cerebral edema or effusion and with cerebral hemorrhages. Extensive safety monitoring is therefore required, including scheduled MRI scans. Also in 2023, brexpiprazole became the first agent specifically approved by the FDA for agitation associated with AD. Suvorexant, an orexin receptor antagonist, previously was approved for the treatment of insomnia in people with mild and moderate AD.

ESSENTIAL POINTS

There is robust evidence for the use of acetylcholinesterase inhibitors for patients with mild, moderate, and severe dementia due to AD, including outcomes beyond changes in cognitive screening test scores. More limited studies support the use of memantine in moderate and severe stages. These agents have a primary effect of delaying decline in cognition and function and postponing the emergence of adverse behaviors. Pharmacotherapy for behavioral and psychological symptoms is less predictable, and most clinical trials have had negative results. Anti-amyloid therapies provide the first FDA-approved option to alter AD pathology, but an understanding of overall utility and value to patients remains in its infancy.

Measuring clinically relevant change in apathy symptoms in ADMET and ADMET 2

OBJECTIVES

Among participants with Alzheimer's disease (AD) we estimated the minimal clinically important difference (MCID) in apathy symptom severity on three scales.

DESIGN

Retrospective anchor- and distribution-based analyses of change in apathy symptom scores.

SETTING

Apathy in Dementia Methylphenidate Trial (ADMET) and ADMET 2 randomized controlled trials conducted at three and ten clinics specialized in dementia care in United States and Canada, respectively.

PARTICIPANTS

Two hundred and sixty participants (60 ADMET, 200 ADMET 2) with clinically significant apathy in Alzheimer's disease.

MEASUREMENTS

The Clinical Global Impression of Change in Apathy scale was used as the anchor measure and the MCID on the Neuropsychiatric Inventory - Apathy (NPI-A), Dementia Apathy Interview and Rating (DAIR), and Apathy Evaluation Scale-Informant (AES-I) were estimated with linear mixed models across all study visits. The estimated thresholds were evaluated with performance metrics.

RESULTS

Among the MCID was a decrease of four points (95% CI: -4.0 to -4.8) on the NPI-A, 0.56 points (95% CI: -0.47 to -0.65) on the DAIR, and three points on the AES-I (95% CI: -0.9 to -5.4). Distribution-based analyses were largely consistent with the anchor-based analyses. The MCID across the three measures showed ∼60% accuracy. Sensitivity analyses found that MMSE scores and apathy severity at baseline influenced the estimated MCID.

CONCLUSIONS

MCIDs for apathy on three scales will help evaluate treatment efficacy at the individual level. However, the modest correspondence between MCID and clinical impression of change suggests the need to consider other scales.

Safety, tolerability, and efficacy outcomes of the Investigation of Levetiracetam in Alzheimer's disease (ILiAD) study: a pilot, double-blind placebo-controlled crossover trial

OBJECTIVE

To assess whether the antiseizure medication levetiracetam may improve cognition in individuals with Alzheimer's disease who have not previously experienced a seizure.

METHODS

We performed a randomized, double-blind, placebo-controlled crossover pilot study in individuals with mild-to-moderate Alzheimer's disease. Electroencephalography was performed at baseline and those with active epileptiform discharges were excluded. Eligible participants were randomized to placebo for 12 weeks or an active arm of oral levetiracetam (4 weeks up-titration to levetiracetam 500 mg twice daily, 4 weeks maintained on this dose followed by 4 weeks down-titration to nil). Participants then crossed over to the other arm. The primary outcome was change in cognitive function assessed by the Oxford Memory Task, a task sensitive to hippocampal memory binding. Secondary outcomes included tolerability, other neuropsychological scales, and general questionnaires.

RESULTS

Recruitment numbers were severely limited owing to restrictions from the COVID-19 pandemic at the time of the study. Eight participants completed both arms of the study (mean age 68.4 years [SD = 9.2]; 5 females [62.5%]). No participants withdrew from the study and there was no significant difference between reported side effects in the active levetiracetam or placebo arm. Measures of mood and quality of life were also not significantly different between the two arms based on participant or carer reports. In limited data analysis, there was no statistically significant difference between participants in the active levetiracetam and placebo arm on the memory task.

SIGNIFICANCE

This pilot study demonstrates that levetiracetam was well tolerated in individuals with Alzheimer's disease who do not have a history of seizures and has no detrimental effect on mood or quality of life. Larger studies are needed to assess whether levetiracetam may have a positive effect on cognitive function in subsets of individuals with Alzheimer's disease.

PLAIN LANGUAGE SUMMARY

Abnormal electrical activity within the brain, such as is seen in seizures, might contribute to memory problems in people with dementia. We completed a clinical trial to see if an antiseizure medication, levetiracetam, could help with memory difficulties in people with Alzheimer's disease (the most common cause of dementia). In this pilot study, we could not prove whether levetiracetam helped memory function. We did show that the drug is safe and well tolerated in people with dementia who have not had a seizure. This work, therefore, offers a platform for future research exploring antiseizure medications in people with dementia.

Predictive, preventive and personalized project of vascular cognitive impairment in China (P3): Study design and interim baseline patient characteristics of a Nationwide multicenter prospective registry

Objectives

To outline the design of the P3 study and serve as a summary of the interim baseline patient characteristics.

Methods

P3 study is a multicenter, prospective cohort study targeting 1000 acute ischemic stroke (AIS) and cerebral small vessel disease (CSVD) patients with a 2-year follow-up from 80 participating hospitals across China. Comprehensive multimodal imaging, neuropsychological tests, and biological samples were collected prospectively on admission and follow-up visits. Patients were interviewed face to face for 2 years and followed up.

Results

Until 30 December 2023, 642 patients were enrolled from 67 centers. In the AIS cohort, 219 patients (72.5%) were diagnosed with acute post-stroke cognitive impairment (PSCI). Compared to those without PSCI, the acute PSCI group exhibited significantly lower levels of education and a history of stroke (all P < 0.05). In the CSVD cohort, 53 patients (41.4%) were diagnosed with cognitive impairment. Compared to those with normal cognitive function, the impaired cognitive function group had a significantly higher prevalence of hypertension and diabetes history (all P < 0.05). All 642 patients completed 20 tests, as well as clinical information and blood sample collection. Nearly 95% of the patients underwent structural MRI and ASL, and 60% of patients completed fMRI and DKI or DTI.

Conclusions

P3 study aims to establish a comprehensive spatiotemporal profile of VCI. Through multidimensional analysis of clinical information, radiomics, proteomics, metabolomics, microbiomics, and genetics, provide a more comprehensive understanding of VCI trajectories and individual variability, enhancing early detection and prognosis management.

Sleep-related measurements to assess sleep disturbances among people living with dementia in nursing homes: a systematic review

BACKGROUND

There is a high prevalence of sleep disturbances among people living with dementia (PLWD) in nursing homes. Reliable and valid measurements are needed to assess these disturbances. The aim of this systematic review was to identify, analyze and synthesize studies of sleep-related measurements to assess sleep disturbances in PLWD.

METHODS

The databases PubMed, CINAHL, and PsycINFO were systematically searched in 2019; the search was updated in March 2024. The inclusion criteria were as follows: participants with dementia or probable dementia in any care setting; and studies that reported at least one of the following aspects: (I) theoretical and conceptual frameworks, (II) user or patient involvement by type of users in measurement development, (III) feasibility and practicability of measurements, and (IV) results of psychometric analyses. The quality of the included studies was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria and the quality appraisal tool for studies of diagnostic reliability (QAREL) tool.

RESULTS

A total of 5169 studies were identified; ultimately, 15 studies describing three self-administered measurements, three proxy-administered measurements and two technological measurements were included. No sleep-related measurement showed acceptable psychometric properties in any of the COSMIN domains.

CONCLUSIONS

No measurement without adaptation can be recommended for PLWD in nursing homes. If existing measurements are used in clinical practice, the self-perspective of PLWD should be taken into account. If this is no longer fully possible, proxy-rating perspectives in combination could be an option. Future research on sleep-related measurements should be strictly based on international consensus-based psychometric quality criteria.

Investigating the Prevalence and Predictors of Apathy among the Canadian Long-Term Care Residents: A Secondary Data Analysis

BACKGROUND

In long-term care facilities (LTCF), apathy is a prevalent issue, leading to cognitive decline, functional impairment, and increased mortality risk. Despite its significance, apathy often remains underrecognized and undermanaged in these settings. Recognizing and addressing the predictors of apathy is critical for early intervention and improved care outcomes.

PURPOSE

This study aims to assess the prevalence of apathy and identify its associated risk factors among newly admitted residents in the Canadian LTCF, using the InterRAI Minimum Data Set (MDS 2.0).

METHODS

We conducted a cross-sectional analysis of MDS 2.0 admission assessment data between 2015 and 2019, covering 157,596 residents across six Canadian provinces and one territory. Apathy was measured using the Apathy Index of the MDS 2.0, with the biopsychosocial model guiding the analysis.

RESULTS

The prevalence of apathy was 12.5% (19,758 individuals). The most significant predictors include cognitive impairments, specific age groups, hearing impairments, vision impairments, facility size and location.

CONCLUSIONS

The findings of this study underscore the need for tailored strategies in LTCF to address apathy, considering individual, institutional, and regional variations. Emphasis on environmental and personal factors is crucial in the management and prevention of apathy in these settings.

Assessing palliative care needs in patients with dementia: A cross-sectional analysis of an predominantly oldest-old population from a geriatric memory clinic

In this cross-sectional study, we assessed palliative care (PC) needs in older adults with dementia. Using the NECPAL CCOMS-ICO© 3.1 tool and comprehensive geriatric assessment, 16.25% of the 554 evaluated patients required PC, which had clinical frailty and a moderate stage of dementia. Advanced frailty was associated with the poorest prognosis, according to the PC-based stratification. Our findings support the use of PC assessment in dementia care, which focuses on a person-centered approach while minimizing unnecessary or ineffective treatments and meeting the real-world patient's needs. PC care may fulfill the multidimensional nature of dementia, shifting towards personalized palliative approaches.

Eating problems in people with dementia with Lewy bodies: Associations with various symptoms and the physician's understanding

OBJECTIVES

Eating problems frequently occur in people with dementia with Lewy bodies (DLB), but few studies have investigated the clinical background of this phenomenon. This study examined the relationship between eating problems and various symptoms of DLB and the relation between the treatment needs for DLB people with eating problems and the understanding of their eating problems by caregivers and physicians.

DESIGN, MEASUREMENTS, AND PARTICIPANTS

This was a subanalysis of a cross-sectional, questionnaire-based survey study. Two hundred sixty-one subjects with DLB were divided into subjects with or without eating problems. Logistic or linear regression analysis was used to investigate the factors influencing eating problems. The treatment needs of DLB people for their eating problems and the understanding of these needs by caregivers and physicians were calculated as participant-caregiver and participant-physician kappa coefficient.

RESULTS

Of the 261 participants, 27% suffered from eating problems. The presence of eating problems in participants with DLB was related to depression (p = 0.01, OR : 2.19, 95% CI: 1.23-3.91) and apathy (p = 0.01, OR 2.15, 95% CI: 1.20-3.87), while the worsening of eating problems was related to dysphagia (β = 0.24, p = 0.03), apathy (β = 0.23, p = 0.05), and nighttime behavior (β = 0.24, p = 0.04). The participant-physician kappa coefficient for physician understanding of constipation, weight loss, dysphagia, weight gain, and increase in appetite was significantly lower than the corresponding participant-caregiver kappa coefficient (p-value of five symptoms < 0.01).

CONCLUSIONS

Physicians need to pay more attention to eating problems and their neuropsychiatric background in the long-term support and management of DLB subjects.

Mediating role of care partner burden among dementia care partners during post-hospital transition

OBJECTIVES

This study examined the mediating role of care partner burden on the relationship between patient clinical factors (i.e. cognition, physical function, and behavioral and psychological symptoms of dementia [BPSD]) and care partner mental health (i.e. anxiety and depression) among dementia care partners at hospital discharge.

METHOD

The sample consisted of 431 patient and care partner dyads enrolled in the Family centered Function-focused Care (Fam-FFC) study; ClinicalTrials.gov identifier NCT03046121. Mediation analyses were conducted to test the role of care partner burden on the associations between patient clinical factors, and care partner anxiety and depression.

RESULTS

Mediation models demonstrated that care partner burden partially mediated the relationship between patient physical function and care partner anxiety and depression, as well as patient BPSD and care partner anxiety and depression.

CONCLUSION

Findings highlight the need for clinicians and service providers to implement comprehensive strategies that address both patient clinical factors (i.e. physical function and BPSD) and care partner burden, to optimize care partner mental health outcomes during post-hospital transition.

Stepwise dual-target magnetic resonance-guided focused ultrasound in tremor-dominant Parkinson disease: One-year follow-up

BACKGROUND AND PURPOSE

Magnetic resonance-guided focused ultrasound (MRgFUS) is a nonsurgical treatment for Parkinson disease (PD). Some selected anatomical structures can be targeted by MRgFUS in PD. However, there is no uniform target yet. We have reported that stepwise dual-target MRgFUS was successfully applied to treat refractory tremors with akinetic-rigid features in PD. It generated two precise thermal ablations in the ventral intermediate nucleus (VIM) and pallidothalamic tract (PTT). Here, we report more PD patients to verify the safety and efficacy of stepwise dual-target MRgFUS.

METHODS

Ten tremor-dominant PD patients (mean age = 66.7 ± 3.2 years, eight men) received the stepwise dual-target MRgFUS treatment with a series of primary and secondary outcome measures. The VIM and PTT were navigated based on brain magnetic resonance images. Outcome measures were categorized into primary and secondary assessments. The primary outcome measures consisted of resting tremor, action/kinetic tremor, rigidity, and bradykinesia. Secondary outcome measures encompassed non-motor symptoms scale of PD. Data collected at follow-up time points, including 1 day, 3 months, 6 months, and 1 year posttreatment, were compared with baseline data.

RESULTS

The severity of tremor and motor deficits represented by Clinical Rating Scale for Tremor parts A and B during off-medication status and Unified Parkinson's Disease Rating Scale III on the treated side were significantly improved (p < 0.05 by paired t-test) at 1-year follow-up. At the 1-year follow-up, significant improvement was observed in the non-motor symptoms scale. Additionally, no severe adverse effects were reported, except temporary treatment-related discomfort during the procedure.

CONCLUSIONS

In conclusion, stepwise dual-target MRgFUS emerges as a safe and effective therapeutic modality for PD patients, particularly in addressing medication-refractory tremor and akinetic-rigid syndrome.

The effectiveness of exercise interventions targeting sleep in older adults with cognitive impairment or Alzheimer's disease and related dementias (AD/ADRD): A systematic review and meta-analysis

Sleep loss is associated with reduced health and quality of life, and increased risk of Alzheimer's disease and related dementias. Up to 66% of persons with Alzheimer's disease and related dementias experience poor sleep, which can predict or accelerate the progression of cognitive decline. Exercise is a widely accessible intervention for poor sleep that can protect against functional and cognitive decline. No previous systematic reviews have investigated the effectiveness of exercise for sleep in older adults with mild cognitive impairment or Alzheimer's disease and related dementias. We systematically reviewed controlled interventional studies of exercise targeting subjectively or objectively (polysomnography/actigraphy) assessed sleep in persons with mild cognitive impairment or Alzheimer's disease and related dementias. We conducted searches in PubMed, Embase, Scopus and Cochrane-Library (n = 6745). Nineteen randomised and one non-randomised controlled interventional trials were included, representing the experiences of 3278 persons with mild cognitive impairment or Alzheimer's disease and related dementias. Ten had low-risk, nine moderate-risk, and one high-risk of bias. Six studies with subjective and eight with objective sleep outcomes were meta-analysed (random-effects model). We found moderate- to high-quality evidence for the beneficial effects of exercise on self-reported and objectively-measured sleep outcomes in persons with mild cognitive impairment or Alzheimer's disease and related dementias. However, no studies examined key potential moderators of these effects, such as sex, napping or medication use. Our results have important implications for clinical practice. Sleep may be one of the most important modifiable risk factors for a range of health conditions, including cognitive decline and the progression of Alzheimer's disease and related dementias. Given our findings, clinicians may consider adding exercise as an effective intervention or adjuvant strategy for improving sleep in older persons with mild cognitive impairment or Alzheimer's disease and related dementias.

Structural white matter connectivity differences independent of gray matter loss in mild cognitive impairment with neuropsychiatric symptoms: Early indicators of Alzheimer's disease using network-based statistics

BACKGROUND

Depression and circadian rhythm disruptions are non-cognitive neuropsychiatric symptoms (NPS) that can appear at any stage of the Alzheimer's disease (AD) continuum. Evidence suggests that NPS are linked to AD pathophysiology and hippocampal dysfunction.

OBJECTIVE

To examine structural white matter (WM) connectivity and its association with gray matter (GM) atrophy and to identify specific AD-related neural networks linked to NPS in individuals with mild cognitive impairment (MCI).

METHODS

Ninety-six older adults participants were divided into three groups based on the Global Depression Scale, Neuropsychiatric Inventory, Clinical Dementia Rating, and Mini-Mental Status Examination. Twelve individuals with MCI and NPS (MCI+) and 49 without NPS (MCI-) were classified, along with 35 age and gender-matched healthy individuals. Voxel-based morphometry and tract-based spatial statistics were employed to identify structural and microstructural alterations. Network-based statistics analyzed structural WM connectivity differences between MCI groups and healthy controls.

RESULTS

Significant structural WM connectivity and GM loss were exclusively observed in MCI+ individuals compared to controls. The hippocampus, amygdala, and sensory cortex showed GM atrophy (p < 0.05), while the thalamus, pallidum, putamen, caudate, hippocampus, and sensory and frontal cortices exhibited structural WM connectivity loss (p < 0.01). These data indicate early limbic system involvement even without GM atrophy.

CONCLUSIONS

Structural WM connectivity loss within the Papez circuit may precede and potentially predict GM atrophy in the temporal lobe of individuals with MCI+. These findings highlight the importance of investigating structural WM alterations in the prodromal phase of AD, which may inform diagnostic and therapeutic strategies in early AD.

Computerized decision support to optimally funnel patients through the diagnostic pathway for dementia

BACKGROUND

The increasing prevalence of dementia and the introduction of disease-modifying therapies (DMTs) highlight the need for efficient diagnostic pathways in memory clinics. We present a data-driven approach to efficiently guide stepwise diagnostic testing for three clinical scenarios: 1) syndrome diagnosis, 2) etiological diagnosis, and 3) eligibility for DMT.

METHODS

We used data from two memory clinic cohorts (ADC, PredictND), including 504 patients with dementia (302 Alzheimer's disease, 107 frontotemporal dementia, 35 vascular dementia, 60 dementia with Lewy bodies), 191 patients with mild cognitive impairment, and 188 cognitively normal controls (CN). Tests included digital cognitive screening (cCOG), neuropsychological and functional assessment (NP), MRI with automated quantification, and CSF biomarkers. Sequential testing followed a predetermined order, guided by diagnostic certainty. Diagnostic certainty was determined using a clinical decision support system (CDSS) that generates a disease state index (DSI, 0-1), indicating the probability of the syndrome diagnosis or underlying etiology. Diagnosis was confirmed if the DSI exceeded a predefined threshold based on sensitivity/specificity cutoffs relevant to each clinical scenario. Diagnostic accuracy and the need for additional testing were assessed at each step.

RESULTS

Using cCOG as a prescreener for 1) syndrome diagnosis has the potential to accurately reduce the need for extensive NP (42%), resulting in syndrome diagnosis in all patients, with a diagnostic accuracy of 0.71, which was comparable to using NP alone. For 2) etiological diagnosis, stepwise testing resulted in an etiological diagnosis in 80% of patients with a diagnostic accuracy of 0.77, with MRI needed in 77%, and CSF in 37%. When 3) determining DMT eligibility, stepwise testing (100% cCOG, 83% NP, 75% MRI) selected 60% of the patients for confirmatory CSF testing and eventually identified 90% of the potentially eligible patients with AD dementia.

CONCLUSIONS

Different diagnostic pathways are accurate and efficient depending on the setting. As such, a data-driven tool holds promise for assisting clinicians in selecting tests of added value across different clinical contexts. This becomes especially important with DMT availability, where the need for more efficient diagnostic pathways is crucial to maintain the accessibility and affordability of dementia diagnoses.

Efficacy and safety of Neurocognitive Adaptive Training for Depression combined with SSRIs for treating cognitive impairment among patients with late-life depression: a 12-week, randomized controlled study

BACKGROUND

This randomized, open-label study examined the therapeutic effects of Neurocognitive Adaptive Training for Depression (NCAT-D) combined with selective serotonin reuptake inhibitors (SSRIs) on cognitive impairment among patients with late-life depression (LLD).

METHOD

Study data were collected from May 5, 2021, to April 21, 2023. Outpatients who met the diagnostic criteria for major depressive disorder according to the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (i.e., a total score on the 17-item Hamilton Depression Rating Scale (HAMD-17) ≥ 18 and a total score on the Montreal Cognitive Assessment scale (MOCA) < 26) were recruited at Beijing Anding Hospital. These participants were randomly assigned to receive up to 12 weeks of NCAT-D and SSRIs treatment (n = 57) or SSRIs with a control treatment (n = 61). Primary outcomes included changes in Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) scores from baseline to week 12 between the two groups. Assessments were conducted at baseline, after 2 weeks, 4 weeks, 8 weeks, and at 12 weeks. Mixed model repeated measures (MMRM) analysis was performed on modified intention-to-treat (mITT) and completer populations.

RESULTS

The full analysis set (FAS) included 118 patients (NCAT-D and SSRIs group, n = 57; SSRIs and Control group, n = 61). During the 12-week study period, MMRM analysis revealed a significantly greater reduction in cognitive function (as indicated by ADAS-cog total scores) from baseline to post-treatment in the NCAT-D and SSRIs group compared to the SSRIs and Control groups [(F (1,115) = 13.65, least-squares mean difference [95% CI]: -2.77 [- 3.73, - 1.81], p < 0.001)]. The intervention group showed a significantly greater reduction in HAMD-17 scores compared to the control group [MMRM, estimated mean difference (SE) between groups: -3.59 [- 5.02, - 2.15], p < 0.001]. There was no significant difference in the incidence of adverse events between the two groups.

CONCLUSIONS

NCAT-D combined with SSRIs was efficacious and well tolerated in LLD patients with cognitive impairment.

TRIAL REGISTRATION

Registered on October 18, 2022, at ClinicalTrials.gov Identifier: (#NCT05588102).

A randomized clinical trial evaluating Hydralazine's efficacy in early-stage Alzheimer's disease: The EHSAN Study

Alzheimer's Disease (AD), a neurodegenerative disorder escalating worldwide, remains incurable with existing interventions merely mitigating symptoms. Hydralazine, an antihypertensive agent, has displayed neuroprotective potential in AD animal models via amplification of mitochondrial functionality and stimulation of stress management and repair pathways. Nevertheless, its effectiveness and tolerability in human AD cohorts are yet to be confirmed. This study protocol describes the design of an ongoing, single-center, randomized, triple-blind, placebo-controlled trial to assess hydralazine's effects on cognitive function in mild to moderate -stage AD patients. We will enroll 424 patients aged 50 and older, meeting NINCDS-ADRDA criteria for probable AD with Mini-Mental State Examination scores from 12-26. They'll be randomly assigned to receive either hydralazine HCL (25 mg, thrice daily) or a placebo for 12 months. The primary outcome is the Alzheimer's Disease Assessment Scale change from baseline to 12 months. Secondary outcomes include various measures using Lawton instrumental activities of daily living scale, neuropsychiatry inventory, and caregiver activity survey. This trial will explore the potential benefits and risks of hydralazine in mild to moderate AD treatment. It's the first trial examining hydralazine's impact on mild to moderate -stage AD in human and is registered at the Iranian Registry of Clinical Trials (IRCT20200711048075N1, registered 29/07/2020) and ClinicalTrials.gov (NCT 04,842,552AQ, registered 13/04/2021). Ethics approval was granted by the Research Ethics Committee of the National Institute for Medical Research Development (IR.NIMAD.REC.1398.424), following the SPIRIT Statement guidelines. Findings will be disseminated via peer-reviewed publications and conferences. This inaugural human clinical trial evaluates hydralazine's impact on patients in the mild to moderate AD. Executed with a randomized, triple-blind, placebo-controlled methodology, this study incorporates a significant sample size and an extended monitoring duration. Multiple parameters, including cognitive capabilities, will be assessed. Potential limitations include the inherent homogeneity of the AD cohort, the lack of biomarker assays, and the unpredictable progression of the disease. Notably, the study might not elucidate the protracted effects of hydralazine beyond a 12-month period. Another limitation of our clinical trial is that patients were diagnosed with Alzheimer's disease based solely on clinical evaluation and MRI findings, without the inclusion of specific biomarkers, which may impact the accuracy and specificity of the diagnosis. Trial registration: Iranian Registry of Clinical Trials (IRCT20200711048075N1, registered 29/07/2020) and ClinicalTrials.gov (NCT 04,842,552, registered 13/04/2021).

Italian standardization of the BPSD-SINDEM scale for the assessment of neuropsychiatric symptoms in persons with dementia

Introduction

Behavioral and Psychological Symptoms of Dementia (BPSD) are a heterogeneous set of psychological reactions and abnormal behaviors in people with dementia (PwD). Current assessment tools, like the Neuropsychiatric Inventory (NPI), only rely on caregiver assessment of BPSD and are therefore prone to bias.

Materials and methods

A multidisciplinary team developed the BPSD-SINDEM scale as a three-part instrument, with two questionnaires administered to the caregiver (evaluating BPSD extent and caregiver distress) and a clinician-rated observational scale. This first instrument was tested on a sample of 33 dyads of PwD and their caregivers, and the results were qualitatively appraised in order to revise the tool through a modified Delphi method. During this phase, the wording of the questions was slightly changed, and the distress scale was changed into a coping scale based on the high correlation between extent and distress (r = 0.94). The final version consisted of three 17-item subscales, evaluating BPSD extent and caregiver coping, and the unchanged clinician-rated observational scale.

Results

This tool was quantitatively validated in a sample of 208 dyads. It demonstrated good concurrent validity, with the extent subscale correlating positively with NPI scores (r = 0.64, p &lt; 0.001) and the coping subscale inversely correlating with NPI distress (r = −0.20, p = 0.004). Diagnosis (Lewy body dementia and frontotemporal dementia), medication (antidepressants and antipsychotics), caregiver, and PwD age predicted BPSD burden on the BPSD-SINDEM scale. Caregiver coping was influenced by diagnosis (Alzheimer’s and Lewy body dementia) and benzodiazepine.

Discussion

The BPSD-SINDEM scale offers a more comprehensive approach compared to NPI, by combining caregiver ratings with clinician observations. The design of the scale allows for rapid administration in diverse clinical contexts, with the potential to enhance the understanding and management of BPSD.

Abnormal eye movements: relationship with clinical symptoms and predictive value for Alzheimer's disease

Background

Abnormal eye movements occur at the early stages of Alzheimer's disease (AD). However, the characteristics of abnormal eye movements of patients with AD and their relationship with clinical symptoms remain inconsistent, and their predictive value for diagnosing and monitoring the progression of AD remains unclear.

Methods

A total of 42 normal controls, 63 patients with mild cognitive impairment due to AD (AD-MCI), and 49 patients with dementia due to AD (AD-D) were recruited. Eye movements were assessed using the EyeKnow eye-tracking and analysis system. Cognitive function, neuropsychiatric symptoms, and activities of daily living were evaluated using various rating scales, and correlation analyses and receiver operating characteristic curves were performed.

Results

Patients with AD exhibited increased number of offsets and offset degrees, prolonged offset duration, and decreased accuracy in lateral fixation; reduced accuracy, prolonged saccadic duration, and decreased velocity in prosaccade; decreased accuracy and corrected rate, prolonged corrected antisaccadic duration, and reduced velocity in antisaccade; and reduced accuracy and increased inhibition failures in memory saccade. Eye movement parameters were correlated with global cognition and the cognitive domains of memory, language, attention, visuospatial ability, execution function, and activities of daily living. Subgroup analysis indicated that the associations between eye movements and clinical symptoms in patients with AD were influenced by disease severity and history of diabetes. In the AD-D and AD with diabetes groups, these associations diminished. Nevertheless, the associations persisted in the AD-MCI and AD without diabetes groups. The areas under the curves for predicting AD, AD-MCI, and AD-D were 0.835, 0.737, and 0.899, respectively (all p < 0.05).

Conclusion

Patients with AD exhibit distinct patterns of abnormal eye movements. Abnormal eye movements are significantly correlated with global cognition, multiple cognitive domains, and activities of daily living. Abnormal eye movements have a considerable predictive value for the diagnosis and progression of AD.

Risk of Stroke or Heart Attack in Mild Cognitive Impairment and Subjective Cognitive Impairment

BACKGROUND

The study aimed to identify Mild Cognitive Impairment (MCI) as an alert clinical manifestation of increased probability of major acute vascular events (MVEs), such as Ischemic Stroke and heart attack.

METHODS

In a longitudinal study, 181 (M = 81, F = 100; mean age of 75.8 ± 8.69 years) patients were enrolled and divided into three groups based on diagnosis: Subjective Cognitive Impairment (SCI), amnestic MCI Single Domain (aMCI-SD), and amnestic MCI More Domain (aMCI-MD). Clinical assessment and the presence of vascular risk factors were collected.

RESULTS

The distribution of MVEs showed a higher incidence in the first two years of follow-up of 7.4% in SCI, 12.17% in aMCI-SD, and 8.57% in aMCI-MD. Acute Myocardial Infarction showed a major incidence in one year of follow-up (41%) and in two years of follow-up (29%). Also, Ischemic Stroke showed a major incidence in one year of follow-up (30%) and in two years of follow-up (40%). A statistically significant difference in the progression to dementia was shown (SCI 3.75%; aMCI-SD 10.43%; aMCI-MD 37%; p-value < 0.001).

CONCLUSIONS

MCI is considered an expression of the systemic activation of mechanisms of endothelial damage, representing a diagnosis predictive of increased risk of MVEs.