Clinical diagnosis of dementia

Instrumental activities of daily living in older patients with metastatic prostate cancer: results from the meet-URO network ADHERE prospective study

Instrumental activities of daily living (IADL) are significant health indicators closely related to executive functions and able to detect mild cognitive impairment. A decline in IADL usually precedes ADL limitation, including taking medications, and may therefore predict a cognitive decline. We aimed to investigate the association of patients' IADL score with other clinical factors, with a particular focus on the presence of a caregiver, and the impact on adherence to androgen receptor pathway inhibitors (ARPIs) and survival outcomes within the Meet-URO 5-ADHERE study. It was a large prospective multicentre observational cohort study monitoring adherence to ARPIs in 234 metastatic castrate-resistant PC (mCRPC) patients aged ≥ 70. We observed an association between impaired IADL and lower geriatric G8 scores (p < 0.01), and lower adherence to ARPIs whether assessed by pill counting (p = 0.01) or self-reported by the patient himself (p = 0.03). The combination of an IADL < 6 and the absence of a caregiver resulted in a significantly high risk of non-adherence to the ARPIs at the multivariable analysis (HR 9.23, 95% confidence interval 2.28-37.43, p = 0.01). IADL alongside the geriatric G8 scales represent essential tools to identify frail and less auto-sufficient patients who are extremely vulnerable particularly if not supported by a caregiver and have the highest risk of nonadherence to ARPIs.

Functional changes in brain oscillations in dementia: a review

A growing body of evidence indicates that several characteristics of electroencephalography (EEG) and magnetoencephalography (MEG) play a functional role in cognition and could be linked to the progression of cognitive decline in some neurological diseases such as dementia. The present paper reviews previous studies investigating changes in brain oscillations associated to the most common types of dementia, namely Alzheimer's disease (AD), frontotemporal degeneration (FTD), and vascular dementia (VaD), with the aim of identifying pathology-specific patterns of alterations and supporting differential diagnosis in clinical practice. The included studies analysed changes in frequency power, functional connectivity, and event-related potentials, as well as the relationship between electrophysiological changes and cognitive deficits. Current evidence suggests that an increase in slow wave activity (i.e., theta and delta) as well as a general reduction in the power of faster frequency bands (i.e., alpha and beta) characterizes AD, VaD, and FTD. Additionally, compared to healthy controls, AD exhibits alteration in latencies and amplitudes of the most common event related potentials. In the reviewed studies, these changes generally correlate with performances in many cognitive tests. In conclusion, particularly in AD, neurophysiological changes can be reliable early markers of dementia.

Association of inflammatory bowel disease and related medication exposure with risk of Alzheimer's disease: An updated meta-analysis

Background

Chronic systemic inflammation may be associated with neurocognitive decline, but the relationships between inflammatory bowel disease and related medications and the risk of Alzheimer's disease remain unclear.

Methods

We performed a meta-analysis to evaluate the associations of ulcerative colitis, Crohn's disease and related medications with risk of Alzheimer's disease. We identified cohort and case-control studies by searching PubMed, Embase and Web of Science up to August 2022.

Results

Seven eligible studies with 20,174 cases of Alzheimer's disease were included in the meta-analysis. Six studies reported the association between ulcerative colitis and risk of Alzheimer's disease; five studies reported the association between Crohn's disease and risk of Alzheimer's disease. Meta-analysis combining these studies did not reveal any significant association of ulcerative colitis or Crohn's disease with risk of Alzheimer's disease. The pooled relative risks were 1.16 (95%CI: 0.96, 1.41) and 1.17 (95%CI: 0.84, 1.62) for ulcerative colitis and Crohn's disease, respectively. High heterogeneity was detected across the studies. Of note, there was an inverse association between inflammatory bowel disease related medication exposure and risk of Alzheimer's disease. The pooled relative risk of three studies for Alzheimer's disease was 0.86 (95%CI: 0.75, 0.99). No publication bias was detected.

Conclusion

This study does not support the association of ulcerative colitis and Crohn's disease with the risk of Alzheimer's disease. However, medications for the treatment of inflammatory bowel disease might be associated with a lower risk of Alzheimer's disease.

Development of Random Forest Algorithm Based Prediction Model of Alzheimer's Disease Using Neurodegeneration Pattern

OBJECTIVE

Alzheimer's disease (AD) is the most common type of dementia and the prevalence rapidly increased as the elderly population increased worldwide. In the contemporary model of AD, it is regarded as a disease continuum involving preclinical stage to severe dementia. For accurate diagnosis and disease monitoring, objective index reflecting structural change of brain is needed to correctly assess a patient's severity of neurodegeneration independent from the patient's clinical symptoms. The main aim of this paper is to develop a random forest (RF) algorithm-based prediction model of AD using structural magnetic resonance imaging (MRI).

METHODS

We evaluated diagnostic accuracy and performance of our RF based prediction model using newly developed brain segmentation method compared with the Freesurfer's which is a commonly used segmentation software.

RESULTS

Our RF model showed high diagnostic accuracy for differentiating healthy controls from AD and mild cognitive impairment (MCI) using structural MRI, patient characteristics, and cognitive function (HC vs. AD 93.5%, AUC 0.99; HC vs. MCI 80.8%, AUC 0.88). Moreover, segmentation processing time of our algorithm (<5 minutes) was much shorter than of Freesurfer's (6-8 hours).

CONCLUSION

Our RF model might be an effective automatic brain segmentation tool which can be easily applied in real clinical practice.

Neuropsychological autopsy of testamentary capacity: Methodology and issues in the elderly

The forensic assessment of testamentary capacity is a topical issue given the prevalence of dementia illnesses and the increase in the complexity of modern financial and family structures. Although a contemporaneous assessment would be desirable, the majority of situations require a retrospective assessment of the mental state a deceased individual. Neuropsychologists, independently or as part of a board of consultants, are, therefore, frequently requested to give an expert opinion of the competence of cognitively impaired elderly testators.This paper offers a guide for carrying out a neuropsychological autopsy, namely the process of posthumous evaluation, for determining testamentary capacity. Taking into account the recent literature on the assessment of testamentary capacity, we propose a three-phase procedure for carrying out the neuropsychological autopsy in the forensic context. The neuropsychological autopsy of testamentary capacity is based on the meticulous, chronologically structured evaluation of any medical documents, available psychometric data, along with the critical examination of any source of information about the cognitive level of functioning of the deceased person at the time of the will.

Comparing Sensitivity and Specificity of Addenbrooke's Cognitive Examination-I, III and Mini-Addenbrooke's Cognitive Examination in Parkinson's Disease

Background

Parkinson's disease (PD) is the second most common neurodegenerative disorder characterized by numerous motor and nonmotor symptoms. Neurocognitive disorders (NCD) are one of the most troublesome problems and their diagnosis is often challenging.

Methods

We compared the sensitivity and specificity of several versions of Addenbrooke Cognitive Examination (ACE, ACE-III, and Mini-ACE) on 552 subjects with PD. Normal cognition, mild and major NCD were judged in accordance with the respective criteria of the Diagnostic and Statistical Manual of Mental Disorders 5^th edition. Subsequently, we applied the receiver operation characteristic (ROC) analysis in comparison of different education levels.

Results

For subjects with education level 0–8 and 9–12 years, the ACE-III had the best discriminating capabilities for mild NCD (cut-off scores: 83.5 and 85.5 points, respectively), while Mini-ACE was the best for subjects having education > 12 years (cut-off score: 25.5 points). For detecting major NCD, ACE-III had the best diagnostic accuracy in all levels of education (cut-off scores: 70.5, 77.5, and 78.5 points for subjects having education level 0–8, 9–12, and >12 years, respectively).

Conclusion

ACE-III and its nested version, the Mini-ACE, had the best screening abilities for detecting mild and major NCD in PD.

Towards Consensus on Essential Components of Physical Examination in Primary Care-based Memory Clinics

Background

Primary care-based memory clinics were established to meet the needs of persons with memory concerns. We aimed to identify: 1) physical examination maneuvers required to assess persons with possible dementia in specialist-supported primary care-based memory clinics, and 2) the best-suited clinicians to perform these maneuvers in this setting.

Methods

We distributed in-person and online surveys of clinicians in a network of 67 primary care-based memory clinics in Ontario, Canada.

Results

90 surveys were completed for an overall response rate of 66.7%. Assessments of vital signs, gait, and for features of Parkinsonism were identified as essential by most respondents. There was little consensus on which clinician should be responsible for specific physical examination maneuvers.

Conclusions

While we identified specific physical examination maneuvers deemed by providers to be both necessary and feasible to perform in the context of primary care-based memory clinics, further research is needed to clarify interprofessional roles related to the examination.

Feasibility and Safety of Perilla Seed Oil as an Additional Antioxidative Therapy in Patients with Mild to Moderate Dementia

Dementia is a broad-spectrum terminology for a degenerate in cognitive function severe enough to intervene in activities of daily living. Oxidative stress plays a major role in the neurodegenerative cascade, leading to the irreversible mechanism in dementia. Perilla seed oil is extracted from its seeds and contains a high source of antioxidative substances such as omega-3 fatty acid. With its prominent antioxidative property, perilla seed oil demonstrates neuroprotective effects against dementia in preclinical studies. We aim to prove the feasibility and safety of perilla seed oil as an additional antioxidative therapy in patients with dementia. This single-centered, double-blinded, placebo-controlled trial randomized 239 patients with clinical diagnosis of mild to moderate dementia according to the Thai Mini-Mental State Examination (TMSE) score of 10 to 23 or the Thai Montreal Cognitive Assessment score of 12 to 25. Either two capsules containing 500 milligrams of perilla seed oil or similarly appearing two capsules containing 500 milligrams of olive oil (placebo) four times daily was added to conventional standard treatment of dementia for six months. Clinical side effects and routine laboratory results at baseline and after treatment were compared between both groups. Nausea and vomiting were the most common clinical side effects (3%) found equally in both groups. Three patients in the placebo group prematurely discontinued the medication, while only one patient in the treatment group quit the medication early. However, about 5% of patients in both groups could not comply with the regimen of the treatment. The routine laboratory results, including complete blood counts, kidney function tests, and liver function panels, at baseline and after treatment, were not significantly different in both groups. In conclusion, perilla seed oil was feasible and safe to add on with standard treatment in patients with mild to moderate dementia. Further study is needed to confirm its benefit to use as additional antioxidative therapy in patients with dementia.

Application of Optical Coherence Tomography in the Detection and Classification of Cognitive Decline

Aim

This review aims to critically analyze the current literature on the relationship of optical coherence tomography (OCT) measures to cognition and dementia.

Background

Optical coherence tomography, a noninvasive method of imaging neuroretinal layers, and OCT angiography, a highly precise method of examining retinal vasculature, have widely been used to aid in the diagnosis and monitoring of a variety of ocular diseases. There is now an increasing body of evidence relating the structural and microvascular changes of the retina to cognitive impairment.

Review results

In general, several studies have found decreased retinal nerve fiber layer (RNFL) thickness in Alzheimer’s disease (AD) and mild cognitive impairment (MCI) and an association between RNFL thickness and continuous measures of cognitive ability, though findings were inconsistent across studies. In many studies, associations were found for specific regions of the RNFL but not with overall thickness. Studies linking OCT measures to non-Alzheimer’s dementia were lacking, and limited work has been done on persons with past cognitive decline but who remain cognitively normal (the ideal stage at which to target treatment). Common limitations of prior studies include a failure to account for intraocular pressure (IOP) and axial length.

Conclusion

Current research suggests a potential association between retinal findings observed on OCT and cognitive impairment. Methodologically robust research accounting for important covariates and looking at changes in OCT and/ or cognition is needed to better characterize the association between OCT and cognitive ability.

Clinical significance

Further research is warranted to determine whether OCT findings can help identify the etiology of cognitive decline and/or serve as objective markers of AD. If this is the case, OCT may also help identify the presence of disease processes in cognitively normal individuals.

How to cite this article: Lee MJ, Abraham AG, Swenor BK, Sharrett AR, Ramulu PY. Application of Optical Coherence Tomography in the Detection and Classification of Cognitive Decline. J Curr Glaucoma Pract 2018;12(1):10-18.

RBANS memory percentage retention: No evidence of incremental validity beyond RBANS scores for diagnostic classification of mild cognitive impairment and dementia and for prediction of daily function

RBANS percentage retention scores may be useful for diagnosis, but their incremental validity is unclear. Percentage retention versus RBANS immediate and delayed memory subtests and delayed index scores were compared for diagnostic classification and for prediction of function. Data from 173 memory clinic patients with an interdisciplinary diagnosis (no cognitive impairment, amnestic mild cognitive impairment [aMCI], and dementia due to Alzheimer's disease [AD]) and complete RBANS data were analyzed. Across diagnostic contrasts, list percentage retention classification accuracy was similar to List Learning delayed recall, but below the Delayed Memory Index (DMI). Similarly, for classifying no cognitive impairment versus aMCI or dementia due to AD, story percentage retention was similar to Story Memory subtests and below the DMI. For classifying aMCI versus AD; however, Story Memory exceeded the DMI, but was similar to Story Memory subtest scores. Similarly, for prediction of function percentage retention measures did not predict variance beyond that predicted by the RBANS subtest or index scores. In sum, there is no evidence that calculation of percentage retention for RBANS adds clinical utility beyond those provided by the standard RBANS scores.

Neuropsychiatric Symptoms in a Cohort of Patients with Frontotemporal Dementia: Our Experience

INTRODUCTION

About 20-50% of relatively young onset dementia belongs to frontotemporal type. Most of these patients are diagnosed as psychiatric illness as their memory and instrumental activities of daily living remain unaltered till late and most of these patients do not qualify for dementia by the Diagnostic and Statistical Manual of Mental Disorders-IV criteria. In this study, we analyzed the behavioral symptoms in our patients with radiologically and neuropsychologically proven as probable behavioral variant of frontotemporal dementia (FTD).

PATIENTS AND METHODS

Twenty patients qualifying the International Consensus Criteria were included and evaluated using National Institute of Mental Health and Neurosciences neuropsychological battery in addition to all mandatory dementia workup.

RESULTS

The mean age was 53.9 ± 9.9 years and the mean duration of illness was 2 ± 1.3 years. Sixty percent of them were <60 years. There were 9 males and 11 females. Most common heralding symptom noticed in 85% of the patients was irritability and aggression as against apathy in 100% in western studies. Memory impairment was found in only 11.1% as against 25% in western studies. Disinhibition, eating problems, stereotyped behavior, delusions, and paranoia were comparable between the study population and literature.

DISCUSSION AND CONCLUSION

There are minor variations in the neuropsychological manifestations in our patients compared to western population. Agitation and aggression are more and memory impairment is very less making the diagnosis of FTD possible only if there is a high degree of suspicion. These symptoms are less amenable for pharmacotherapy and therefore, there is a need to explore the benefits of nonpharmacological treatment options such as yoga and meditation.

RBANS embedded measures of suboptimal effort in dementia: effort scale has a lower failure rate than the effort index

The importance of evaluating effort in neuropsychological assessments has been widely acknowledged, but measuring effort in the context of dementia remains challenging due to the impact of dementia severity on effort measure scores. Two embedded measures have been developed for the repeatable battery for the assessment of neuropsychological status (RBANS; Randolph, C., Tierney, M. C., Mohr, E., & Chase, T. N. (1998). The repeatable battery for the assessment of neuropsychological status (RBANS): Preliminary clinical validity. Journal of Clinical and Experimental Neuropsychology, 20 (3), 310-319): the Effort Index (EI; Silverberg, N. D., Wertheimer, J. C., & Fichtenberg, N. L. (2007). An effort index for the repeatable battery for the assessment of neuropsychological status (RBANS). Clinical Neuropsychologist, 21 (5), 841-854) and the Effort Scale (ES; Novitski, J., Steele, S., Karantzoulis, S., & Randolph, C. (2012). The repeatable battery for the assessment of neuropsychological status effort scale. Archives of Clinical Neuropsychology, 27 (2), 190-195). We explored failure rates on these effort measures in a non-litigating mixed dementia sample (N = 145). Failure rate on the EI was high (48%) and associated with dementia severity. In contrast, failure on the ES was 14% but differed based on type of dementia. ES failure was low (4%) when dementia was due to Alzheimer disease (AD), but high (31%) for non-AD dementias. These data raise concerns about use of the RBANS embedded effort measures in dementia evaluations.

Clinical correlates of awareness for balance, function, and memory: evidence for the modality specificity of awareness

Awareness in dementia is increasingly recognized not only as multifactorial, but also as domain specific. We demonstrate differential clinical correlates for awareness of daily function, awareness of memory, and the novel exploration of awareness of balance. Awareness of function was higher for participants with mild cognitive impairment (aMCI and non-aMCI) than for those with dementia (due to Alzheimer disease; AD and non-AD), whereas awareness of memory was higher for both non-aMCI and non-AD dementia patients than for those with aMCI or AD. Balance awareness did not differ based on diagnostic subgroup. Awareness of function was associated with instrumental activities of daily living and caregiver burden. In contrast, awareness of balance was associated with fall history, balance confidence, and instrumental activities of daily living. Clinical correlates of awareness of memory depended on diagnostic group: associations held with neuropsychological variables for non-AD dementia, but for patients with AD dementia, depression and instrumental activities of daily living were clinical correlates of memory awareness. Together, these data provide support for the hypothesis that awareness and dementia are not unitary and are, instead, modality specific.

Content and quality of information provided on canadian dementia websites

Purpose

Information about dementia is important for persons with dementia (PWD) and their caregivers and the Internet has become the key source of health information. We reviewed the content and quality of information provided on Canadian websites for Alzheimer’s disease (AD).

Methods

We used the terms “dementia” and “Alzheimer” in Google to identify Canadian dementia websites. The contents of websites were compared to 16 guideline recommendations provided in Canadian Consensus Conference on Diagnosis and Treatment of Dementia. The quality of information provided on websites was evaluated using the DISCERN instrument. The content and quality of information provided on selected websites were then described.

Results

Seven websites were identified, three of which provided relatively comprehensive and high-quality information on dementia. Websites frequently provided information about diagnosis of dementia, its natural course, and types of dementia, while other topics were less commonly addressed. The quality of information provided on the websites varied, and many websites had several areas where the quality of information provided was relatively low according to the DISCERN instrument.

Conclusions

There is variation in the content and quality of dementia websites, although some websites provide high-quality and relatively comprehensive information which would serve as a useful resource for PWD, caregivers, and healthcare providers. Improvements in the content and quality of information provided on AD websites would provide PWD and their caregivers with access to better information.

Development and evaluation of a telehealth videoconferenced support group for rural spouses of individuals diagnosed with atypical early-onset dementias

Atypical and early-onset dementias can be particularly problematic for family caregivers, and support groups aimed at memory loss and Alzheimer’s disease are not always helpful. Unfortunately, little has been developed specifically for caregivers of individuals with atypical dementias such as the frontotemporal dementias. Compounding the lack of access to interventions targeted specifically at caregivers of individuals with atypical and early-onset dementias are the unique needs of rural caregivers. Due to the relative infrequency of these particular dementias and the large geographical distances between rural caregivers, technology-facilitation is required for any group-based intervention. This paper describes the development of a secure telehealth videoconferenced support group for rural spouses of individuals with atypical and early-onset dementias. In addition, we provide preliminary evidence of effectiveness and describe a template for future groups based on the key therapeutic aspects of this novel technology-facilitated intervention.

Diagnosis of vascular cognitive impairment and its main categories

OBJECTIVE

A review of current criteria for the diagnosis of categories related with vascular cognitive impairment, in particular the nomenclature, diagnostic criteria, and differential clinical-radiological findings.

DEVELOPMENT

The criteria for the diagnosis of vascular cognitive impairment have evolved, but available criteria were designed basically for differentiating between vascular dementia and dementia due to Alzheimer disease, and for research purposes. Nevertheless, in clinical practice precise elements are required for: 1) Clinical diagnosis of dementia and mild cognitive impairment; 2) Clinical and neuroimaging criteria for identification of the various cerebrovascular lesions associated with cognitive dysfunction, and 3) A formulation of the aetiogenic-pathogenic relationship between cognitive impairment and cerebrovascular lesions. For this reason, a review was carried out on the diagnostic elements of vascular cognitive impairment categories, classification, and their most relevant characteristics. It highlights the characteristic for the diagnosis of multi-infarction dementia, strategic single infarct dementia, small vessel disease with dementia, mixed dementia, and vascular mild cognitive impairment.

CONCLUSIONS

Standardisation is required, by a multidisciplinary expert team, as regards nomenclature and criteria for the diagnosis of the full spectrum associated with vascular cognitive impairment and especially for vascular dementia and its categories.

Management of suspected Alzheimer's disease patients by specialist physicians at the first visit in Spain: First Consultation Study

OBJECTIVE

To assess the management of suspected Alzheimer's disease (AD) patients at the first visit by Spanish specialist physicians.

MATERIALS & METHODS

Epidemiological, cross-sectional and multicenter study. A total of 200 specialists (neurologists, psychiatrists and geriatricians) from hospitals and specialized centers across Spain included a total of 1851 patients of both sexes older than 18 years suspected to be suffering from AD. Data of clinical and demographic characteristics, methods of diagnosis, treatments and follow-up were collected in one visit.

RESULTS

The mean age of the population was 75.2 ± 7.9 years. The most frequent symptoms were difficulty in performing familiar tasks (76.7%), memory loss (76.0%) and misplacing items (72.7%). The assessment of suspected AD subjects included: neurological examination (walk apraxia [10.8%] and extrapyramidal signs [10.7%]), evaluation of cognition (mean of the Mini-Mental State Examination score was 19.9 ± 5.2 [mild AD]), function and behavior, and supplementary diagnostic tests (blood test [90%] and computerized axial tomography [66.8%]). In total, 69.5% of the patients were diagnosed with AD according to Spanish Society of Neurology criteria. Principal treatment was cholinesterase inhibitors (87.8%). The mean time for follow-up visit: 4 ± 2.4 months; with the same physician (95.5%), neurologist (68.2%), psychiatrist (19%) and geriatrician (11.7%).

CONCLUSIONS

Several possible areas are amenable to improvement by means of reducing the time to diagnosis, increasing the number of patients treated with nonpharmacological therapy, and providing more information on the benefits of treatment, care and providing the best therapeutic options available. In this study, almost half of the patients took 1-3 years to visit a physician after appearance of the first symptoms. Significant differences were observed between the medical specialty and treatments provided; nevertheless, the majority of physicians used cholinesterase inhibitors (87.8%) as the principal treatment.

Stress and burden among caregivers of patients with Lewy body dementia

PURPOSE

Patients with Lewy body dementia (LBD) may present a unique set of symptoms and challenges to family caregivers compared with other types of dementia. Prominent difficulties include motor impairment, activities of daily living (ADLs) disability, recurrent behavioral and emotional problems (BEPs), and diagnostic difficulties. These problems are likely to affect caregivers' subjective burden.

DESIGN AND METHODS

The present study used data from an Internet survey conducted by the Lewy Body Dementia Association. Respondents were 611 people who indicated that they were currently involved in the care of their relative with LBD. Subjective burden was assessed with a 12-item short version of the Zarit Burden Interview.

RESULTS

A factor analysis revealed 3 dimensions of burden: role strain, personal strain, and worry about performance. Multiple regressions were used to examine predictors of these dimensions. BEPs, ADL disability, isolation, caregiver age, and patient gender were significant predictors of specific factors. Falls, formal service use, difficulty finding a physician, and evaluation of the physician had no significant associations with burden.

IMPLICATIONS

These findings highlight burden experiences by caregivers of patients with LBD and the impact of BEPs, ADL assistance, and awareness about LBD on subjective burden.

Theory of mind ability in the behavioural variant of frontotemporal dementia: an analysis of the neural, cognitive, and social levels

The paper reviews convergent evidence on the ability to attribute mental states to one's self and to others (i.e., theory of mind, ToM) in patients affected by the behavioural variant of frontotemporal dementia (bv-FTD). This disease represents a particular challenge for researchers and clinicians, due to its insidious onset and ambiguous clinical features, which frequently render difficult a precise and timely diagnosis. The paper proposes a way to shed new light on the hypothesis that the neuropsychiatric profile of individuals with bv-FTD can be at least partially explained by a deficit in ToM ability. We examined both neuroimaging data on the neural correlates of ToM ability in healthy participants and studies investigating the progressive cerebral atrophy in patients with bv-FTD. Our findings suggest a link between the progressive degeneration of the anterior regions of medial frontal structures characterising the early stages of the bv-FTD and the ToM deficit these patients show. They also suggest the importance of using ToM tests during the diagnostic process of bv-FTD.

Light therapy for managing cognitive, sleep, functional, behavioural, or psychiatric disturbances in dementia

BACKGROUND

Rest-activity and sleep-wake cycles are controlled by the endogenous circadian rhythm generated by the suprachiasmatic nuclei (SCN) of the hypothalamus. Degenerative changes in the SCN appear to be a biological basis for circadian disturbances in people with dementia, and might be reversed by stimulation of the SCN by light.

OBJECTIVES

The review assesses the evidence of effectiveness of light therapy in managing cognitive, sleep, functional, behavioural, or psychiatric disturbances associated with dementia.

SEARCH STRATEGY

The Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS were searched on 4 March 2008 using the terms: "bright light*", "light box*", "light visor*", "dawn-dusk*", phototherapy, "photo therapy", "light therapy" "light treatment", light* . The CDCIG Specialized Register contains records from all major health care databases (The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS) as well as from many trials databases and grey literature sources.

SELECTION CRITERIA

All relevant, randomized clinical trials in which light therapy, at any intensity and duration, was compared with a control group for the effect on managing cognition, sleep, function, behavioural, or psychiatric disturbances (as well as changes in institutionalization rates or cost of care) in people with dementia of any type and degree of severity.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed the retrieved articles for relevance and methodological quality, and extracted data from the selected studies. Statistically significant differences in outcomes between the treatment and control groups at end of treatment and follow-up were examined. Each study was summarized using a measure of effect (e.g. mean difference).

MAIN RESULTS

Eight trials met the inclusion criteria. However, three of the studies could not be included in the analyses because of inappropriate reported study analyses or inability to retrieve the required data from the investigators. This review revealed no adequate evidence of the effectiveness of light therapy in managing cognition, sleep, function, behaviour, or psychiatric disturbances associated with dementia.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the value of light therapy for people with dementia. Most of the available studies are not of high methodological quality and further research is required.

Physical activity programs for persons with dementia

BACKGROUND

There is some evidence that physical activity delays the onset of dementia in healthy older adults and slows down cognitive decline to prevent the onset of cognitive disability. Studies using animal models suggest that physical activity has the potential to attenuate the pathophysiology of dementia. 'Physical activity' refers to 'usual care plus physical activity'.

OBJECTIVES

Primary: do physical activity programs maintain or improve cognition, function, behaviour, depression, and mortality compared to usual care in older persons with dementia?Secondary: do physical activity programs have an indirect positive impact on family caregivers' health, quality of life, and mortality compared to family caregivers of older persons with dementia who received usual care alone? Do physical activity programs reduce the use of health care services (e.g., visits to the emergency department) compared to usual care in older persons with dementia and their family caregiver?

SEARCH STRATEGY

The trials were identified from searches of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group, The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS on 9 September 2007 using the search terms: exercise OR "physical activity" OR cycling OR swim* OR gym* OR walk* OR danc* OR yoga OR "tai chi".

SELECTION CRITERIA

All relevant, randomized controlled trials in which physical activity programs were compared with usual care for the effect on managing or improving cognition, function, behaviour, depression, and mortality in people with dementia of any type and degree of severity. Secondary outcomes related to the family caregiver(s) included quality of life, mortality, and use of health care services were intended to be examined.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the retrieved articles for relevance and methodological quality, and extracted data from the selected trials. These were pooled were appropriate.

MAIN RESULTS

Four trials met the inclusion criteria. However, only two trials were included in the analyses because the required data from the other two trials were not made available. Only one meta-analysis was conducted. The results from this review suggest that there is insufficient evidence of the effectiveness of physical activity programs in managing or improving cognition, function, behaviour, depression, and mortality in people with dementia. Few trials have examined these important outcomes. In addition, family caregiver outcomes and use of health care services were not reported in any of the included trials.

AUTHORS' CONCLUSIONS

There is insufficient evidence to be able to say whether or not physical activity programs are beneficial for people with dementia.

Diagnosis and treatment of dementia: 2. Diagnosis

BACKGROUND

Dementia can now be accurately diagnosed through clinical evaluation, cognitive screening, basic laboratory evaluation and structural imaging. A large number of ancillary techniques are also available to aid in diagnosis, but their role in the armamentarium of family physicians remains controversial. In this article, we provide physicians with practical guidance on the diagnosis of dementia based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, held in March 2006.

METHODS

We developed evidence-based guidelines using systematic literature searches, with specific criteria for study selection and quality assessment, and a clear and transparent decision-making process. We selected studies published from January 1996 to December 2005 that pertained to key diagnostic issues in dementia. We graded the strength of evidence using the criteria of the Canadian Task Force on Preventive Health Care.

RESULTS

Of the 1591 articles we identified on all aspects of dementia diagnosis, 1095 met our inclusion criteria; 620 were deemed to be of good or fair quality. From a synthesis of the evidence in these studies, we made 32 recommendations related to the diagnosis of dementia. There are clinical criteria for diagnosing most forms of dementia. A standard diagnostic evaluation can be performed by family physicians over multiple visits. It involves a clinical history (from patient and caregiver), a physical examination and brief cognitive testing. A list of core laboratory tests is recommended. Structural imaging with computed tomography or magnetic resonance imaging is recommended in selected cases to rule out treatable causes of dementia or to rule in cerebrovascular disease. There is insufficient evidence to recommend routine functional imaging, measurement of biomarkers or neuropsychologic testing.

INTERPRETATION

The diagnosis of dementia remains clinically integrative based on history, physical examination and brief cognitive testing. A number of core laboratory tests are also recommended. Structural neuroimaging is advised in selected cases. Other diagnostic approaches, including functional neuroimaging, neuropsychological testing and measurement of biomarkers, have shown promise but are not yet recommended for routine use by family physicians.