Occurrence of neuropsychiatric symptoms and psychiatric disorders in mild Alzheimer's disease and mild cognitive impairment subtypes

Prevalence of psychotic symptoms in mild cognitive impairment: A systematic review and meta-analysis

INTRODUCTION

Neuropsychiatric symptoms may impact prognosis in individuals with mild cognitive impairment (MCI); however, data on frequency of psychotic symptoms are sparse.

METHODS

We searched MEDLINE, EMBASE, PsychoINFO from inception to June 2023. We included studies reporting patients with MCI prevalence of (delusions and/or hallucinations. Random effects model were performed to estimate the prevalence, and subgroup and meta-regression analyses were performed to explore heterogeneity.

RESULTS

Of 3145 records identified, 36 studies were included, enrolling 20,426 patients. Overall prevalence of hallucinations was 1.78 % (95 % CI, 1.17 - 2.71) and delusions 3.84 % (95 % CI, 2.71 - 5.42), both with significant heterogeneity (/2 = 90 %). Prevalence of hallucinations and delusions were lower when measured by NPI scales and in population-based samples.

DISCUSSION

Delusions and hallucinations occur in MCI patients at low rates. Prevalence can be partially explained by the assessment method, sample source and study heterogeneity.

Eating Frequency, Timing, and Duration in Relation to Cognitive Performance and Alzheimer Disease Biomarkers in Adults

BACKGROUND

The potential association between temporal dimensions of eating and cognition/cognitive declines has been poorly investigated so far.

OBJECTIVES

The aim of this study was to examine relationships among eating frequency, timing and time window, and cognitive performance and novel Alzheimer disease (AD) biomarkers in cognitively healthy and mildly cognitively impaired middle-aged and older adults.

METHODS

Cross-sectional data were derived from the Aiginition Longitudinal Biomarker Investigation of Neurodegeneration (ALBION) cohort study, including people aged 40 y or older who have a positive family history of cognitive disorder or cognition-related concerns. Cognitive performance was assessed by a battery of neuropsychological tests. Amyloid β (Αβ42), a biomarker of AD-related pathology, was measured in cerebrospinal fluid. Eating frequency, timing, and the eating time window between the first and the last meal were estimated using time-related information recorded in four 24-h recalls.

RESULTS

Study participants had, on average, 5.3 ± 1.2 eating episodes per day, consumed at 8:20 ± 1.3 and 21:14 ± 1.3 h their first and their last eating episode, respectively, while their eating time window was 12.9 ± 1.6 h. Eating frequency, but not eating time window, was positively associated with global cognition, executive and language performance even after controlling for age, sex, education, BMI, and Mediterranean diet. Increasing eating frequency by 1 eating episode per day was associated with 0.169 higher global z-score. Furthermore, compared with ≤4, having 5-6 or >6 eating episodes per day was associated with better global and memory z-scores. Time of last eating episode was also positively associated with language performance. No associations were detected among eating frequency, timing and window, and AD pathology.

CONCLUSIONS

An eating pattern characterized by less frequent eating and/or by earlier times is present in individuals with worse cognitive performance. Our results shed light on the relevance of temporal eating patterns as potential early markers of behavioral or metabolic changes related to AD pathology.

Prevention, Assessment, and Management of Malnutrition in Older Adults with Early Stages of Cognitive Disorders

Malnutrition is common in older adults, and its risk is greater in those living with dementia. Relative to cognitively healthy peers, the prevalence of malnutrition is also increased in individuals with early stages of cognitive disorders owing to pathophysiological, cognitive, and psychosocial changes related to cognitive impairment. Malnutrition is associated with adverse health outcomes, including faster cognitive and functional decline. Here, we provide an overview of the prevention, assessment, and management of malnutrition in older adults, with a special focus on the aspects that are important to consider in individuals with early stages of cognitive disorders. Strategies to prevent malnutrition include systematic screening for malnourishment using validated tools to detect those at risk. If the screening reveals an increased risk of malnutrition, a detailed assessment including the individual's nutritional, medical, and functional status as well as dietary intake should be performed. The management of malnutrition in the early stages of cognitive disorders should be based on the findings of a comprehensive assessment and be personalized according to the individual's specific characteristics. In the article, we also provide an overview of the evidence on vitamin supplements and specific dietary patterns to prevent cognitive decline or attenuate its progression.

Visual art therapy and its effects in older people with mild cognitive impairment: A systematic review

INTRODUCTION

Mild cognitive impairment (MCI) is a known risk factor for the development of dementia. The potential benefits on cognition from non-pharmacological measures such as art-based interventions are of increasing interest. This systematic review examines the evidence for the impact of one form of art-based intervention, visual art therapy (VAT), on the cognition and psychological wellbeing of older people with MCI.

METHODS

Randomised controlled and quasi-experimental trials evaluating the efficacy of VAT in older persons aged over 60 years with MCI were included. A search was performed on electronic databases: MEDLINE, CINAHL, Embase and PsycINFO. Joanna Briggs Institute critical appraisal and extraction tools were utilised for risk of bias assessment and data extraction, respectively. A narrative descriptive approach was used to outline the findings.

RESULTS

Seven studies were identified from 4311 articles screened. Improvement in cognition was reported in five studies, with two of these reporting sustained improvement at 6-9 months, while the remaining three studies showed improvement only at the immediate post-intervention period. A positive impact was reported in four of six studies that examined the effect of VAT on participant psychological wellbeing. The overall methodological quality of the studies ranged from moderate in four of five RCTs, to high in the quasi-experimental studies and one RCT. However, the low study power in the context of small sample sizes limits the applicability of these studies to the population of interest.

CONCLUSIONS

VAT is potentially an effective non-pharmacological intervention that may enhance cognition and provide benefits for psychological wellbeing in older persons with MCI. Given the limited studies available, with the majority emerging over the last 5 years, further research is required to confirm these reported benefits, as well as to determine whether VAT impacts on the progression of cognitive decline in MCI.

The Effect of Apathy and Depressive Syndromes on Functional Outcomes in Alzheimer's Disease

Background

Alzheimer's disease (AD) is the most common cause of dementia. Its initially characterized by progressive short-term memory loss followed by cross-domain cognitive decline in later stages resulting in significant functional deficits and loss of activities of daily living (ADLs) independence. Apathy and depression are frequent neuropsychiatric sequelae in AD, but their contribution to functional deficits is poorly understood.

Objective

We aimed to quantitatively investigate if apathy and depressive symptoms predict ADLs in AD. We also wanted to fractionate apathy dimensions by factor-analyzing the apathy evaluation scale (AES) and then investigate the dimensions' relation to ADLs.

Methods

We recruited a sample of 115 patients with probable or possible AD and assessed them for depression, apathy, and ADLs alongside other measures. We hypothesized that apathy and depressive symptoms would predict ADLs and that AES items will load into cognitive, behavioral, and affective factors that would differentially relate to ADLs.

Results

Our results indicated that apathy symptoms predict ADLs deficits. The AES items resolved into a three-factor solution but the manner of clustering diverged from that proposed by AES authors. When these factors were regressed simultaneously, only behavioral apathy predicted global ADLs. Distinguishing basic from instrumental ADLs showed that behavioral and cognitive apathy symptoms associate with ADLs deficits while affective symptoms do not.

Conclusions

Our results highlight the influence of apathy on ADLs in AD. This has important implications for patient care considering the high prevalence of apathy in AD and other dementing illnesses.

Nutrition in Alzheimer's disease: a review of an underappreciated pathophysiological mechanism

Alzheimer's disease (AD) is the leading cause of dementia in older individuals and is an escalating challenge to global public health. Pharmacy therapy of AD is one of the well-funded areas; however, little progress has been made due to the complex pathogenesis. Recent evidence has demonstrated that modifying risk factors and lifestyle may prevent or delay the incidence of AD by 40%, which suggests that the management should pivot from single pharmacotherapy toward a multipronged approach because AD is a complex and multifaceted disease. Recently, the gut-microbiota-brain axis has gained tremendous traction in the pathogenesis of AD through bidirectional communication with multiple neural, immune, and metabolic pathways, providing new insights into novel therapeutic strategies. Dietary nutrition is an important and profound environmental factor that influences the composition and function of the microbiota. The Nutrition for Dementia Prevention Working Group recently found that dietary nutrition can affect cognition in AD-related dementia directly or indirectly through complex interactions of behavioral, genetic, systemic, and brain factors. Thus, considering the multiple etiologies of AD, nutrition represents a multidimensional factor that has a profound effect on AD onset and development. However, mechanistically, the effect of nutrition on AD is uncertain; therefore, optimal strategies or the timing of nutritional intervention to prevent or treat AD has not been established.Thus, this review summarizes the current state of knowledge concerning nutritional disorders, AD patient and caregiver burden, and the roles of nutrition in the pathophysiology of AD. We aim to emphasize knowledge gaps to provide direction for future research and to establish optimal nutrition-based intervention strategies for AD.

Oleocanthal Ameliorates Metabolic and Behavioral Phenotypes in a Mouse Model of Alzheimer's Disease

Aging is a major risk factor for Alzheimer's disease (AD). AD mouse models are frequently used to assess pathology, behavior, and memory in AD research. While the pathological characteristics of AD are well established, our understanding of the changes in the metabolic phenotypes with age and pathology is limited. In this work, we used the Promethion cage systems^® to monitor changes in physiological metabolic and behavioral parameters with age and pathology in wild-type and 5xFAD mouse models. Then, we assessed whether these parameters could be altered by treatment with oleocanthal, a phenolic compound with neuroprotective properties. Findings demonstrated metabolic parameters such as body weight, food and water intake, energy expenditure, dehydration, and respiratory exchange rate, and the behavioral parameters of sleep patterns and anxiety-like behavior are altered by age and pathology. However, the effect of pathology on these parameters was significantly greater than normal aging, which could be linked to amyloid-β deposition and blood-brain barrier (BBB) disruption. In addition, and for the first time, our findings suggest an inverse correlation between sleep hours and BBB breakdown. Treatment with oleocanthal improved the assessed parameters and reduced anxiety-like behavior symptoms and sleep disturbances. In conclusion, aging and AD are associated with metabolism and behavior changes, with the changes being greater with the latter, which were rectified by oleocanthal. In addition, our findings suggest that monitoring changes in metabolic and behavioral phenotypes could provide a valuable tool to assess disease severity and treatment efficacy in AD mouse models.

The Differential Role of Executive Apathy in Alzheimer's Disease Dementia, Mild Cognitive Impairment and Healthy Cognitive Ageing

The objective of the present work was to compare the levels of executive, emotional, and initiation apathy in individuals with mild cognitive impairment (MCI), mild Alzheimer's disease dementia (ADD), and cognitively intact healthy controls (HCs). Fifty-two patients with mild ADD, 40 individuals with MCI, and 37 cognitively intact individuals were included in the current study. The participants were consecutive visitors to the Outpatient Memory Clinic of "Nestor" Alzheimer's Center. The symptoms of apathy were measured with the dimensional apathy scale. Analyses showed that ADD patients had significantly higher degrees of executive, emotional, initiation, and overall apathy compared with both the MCI group and the HCs. Additionally, a significant difference was observed in the dimension of executive apathy between individuals with MCI and the HCs. In conclusion, the dimension of executive apathy was the most sensitive measure regarding the differentiation of individuals with mild ADD or MCI and HCs. Hence, detailed evaluation of executive apathy in older individuals referred to a memory clinic may provide useful information contributing to their diagnostic categorization and to the differentiation between neurocognitive disorders and healthy cognitive ageing.

Validation study of the Persian version of behavioral pathology in Alzheimer's Disease Rating scale (BEHAVE-AD) and the empirical BHAVE-AD (E-BEHAVE-AD)

INTRODUCTION

Behavioral and psychological symptoms of dementia (BPSD) are observed in more than 90% of patients with Alzheimer's disease (AD). BPSDs are remediable if detected early and managed appropriately. Behavioral Pathology in Alzheimer's disease Rating Scale (BEHAVE-AD) and Empirical BEHAVE-AD (E-BEHAVE-AD) were designed to identify BPSD. The aim of this study is to validate and prepare BEHAVE-AD and E-BEHAVE-AD in Persian language for clinical and research applications.

METHOD

120 patients were selected through a combination of intentional and convenience sampling. All participants should fulfill the NINCDS-ADRDA Work Group criteria for a clinical diagnosis of Alzheimer's disease. Functional Assessment Staging Tool (FAST) was used to determine the rate of AD progression. All patients were evaluated using the BEHAVE-AD and E-BEHAVE-AD questionnaires, as well as the Persian version of the Neuropsychiatric Inventory Questionnaire (NPI-Q) and Mini-Mental State Examination (MMSE). The Content Validity Index (CVI) is determined based on the compatibility of the Persian and the original version of the two scales according to the opinion of expert panels. Correlation of MMSE with BEHAVE-AD and E-BEHAVE-AD as well as the BPSD pattern on AD progression continuum by FAST were considered as indices of construct validity. Concurrent validity was estimated by correlating NPI-Q scores with BEHAVE-AD and E-BEHAVE-AD scores. For both scales, interrater reliability was extracted as a reliability index.

RESULTS

Pearson correlation coefficients for the BEHAVE-AD scale were as follows: with NPI-Q (r = 0.77, p-value <0.01), with MMSE (r = -0.34, p-value <0.01), indicating concurrent and construct validity, respectively. The result for E-BEHAVE-AD was as follows: with NPI-Q-total (r = 0.59, p-value <0.01), and with MMSE (r = 0.31, p-value <0. 01). BEHAVE-AD and E-BEHAVE-AD scores increased in parallel with AD severity according to FAST, but not on the most severe AD stage. The area under the curve was estimated to be 0.84 (p-value <0.001) for BEHAVE-AD and 0.78 (p-value <0.001) for E-BEHAVE-AD. Correlation between BEHAVE-AD and E-BEHAVE-AD scores ranged from 0.45 to 0.63. The inter-rater reliability index ranged from 0.88 to 0.99 for BEHAVE-AD and from 0.74 to 0.95 for E-BEHAVE-AD.

CONCLUSIONS

The Persian version of BEHAVE-AD and E-BEHAVE-AD is valid and reliable for the assessment of BPSD in patients with AD.

Intranasal interferon-beta alleviates anxiety and depressive-like behaviors by modulating microglia polarization in an Alzheimer's disease model

Alzheimer's disease (AD) patients frequently experience neuropsychiatric symptoms (NPS), which are linked to a lower quality of life and a faster rate of disease progression. A growing body of research indicates that several microglial phenotypes control the inflammatory response and are crucial in the pathophysiology of AD-related NPS. Given the crucial role played by inflammatory mediators produced by microglia in developing of NPS, interferon-beta (IFNβ), a cytokine with anti-inflammatory capabilities, maybe a successful treatment for NPS caused by AD. In this investigation, using a rat model of AD, we examined the impact of intranasal treatment of IFNβ on anxious/depressive-like behavior and microglial M1/M2 polarization. The rat hippocampus was bilaterally injected with lentiviruses harboring mutant human amyloid precursor protein. Rats were given recombinant IFNβ1a (68,000 IU/rat) via the intranasal route, starting on day 23 following viral infection and continuing until day 49. On days 47-49, the elevated plus maze, forced swim, and tail suspension tests were applied to measure anxiety- and depressive-like behavior. Additionally, qPCR was utilized to quantify the expression of M1 markers (CD68, CD86, and CD40) and M2 markers (Ym1, CD206, Arg1, GDNF, BDNF, and SOCS1). Our findings demonstrated that decreased M2 marker expression is accompanied by anxious/depressive-like behavior when the mutant human APP gene is overexpressed in the hippocampus. In the rat model of AD, IFNβ therapy reduces anxious/depressive-like behaviors, at least in part by polarizing microglia towards M2. Therefore, IFNβ may be a viable therapeutic drug for reducing NPS in the context of AD.

Distinguishing apathy and depression in dementia: A longitudinal study

OBJECTIVES

Apathy is a common symptom in dementia, though can be difficult to distinguish from depression due to shared features and frequent co-occurrence. As such, a significant limitation of much previous research on apathy is the failure to control for depression. The current study sought to address this by examining the trajectory and clinical correlates of apathy after controlling for depression.

METHODS

Seven hundred and seventy-nine patients with dementia were recruited from nine memory clinics around Australia. Measures of dementia severity, cognition, functional ability, neuropsychiatric symptoms, caregiver burden and medication use were completed at baseline and at regular intervals over a 3-year period. Driving and institutionalisation data were obtained throughout the study. Mortality data were obtained from state registries 8 years after baseline.

RESULTS

Of the 662 patients with completed measures of neuropsychiatric symptoms, 342 (51.7%) had apathy and 332 (50.2%) had depression at baseline, while 212 (32.0%) had both. Whereas apathy increased over time, depression remained relatively stable. Apathy, but not depression, was associated with greater dementia severity, poorer cognition and function, driving cessation and mortality. Both apathy and depression were associated with greater neuropsychiatric symptoms, psychosis, caregiver burden and institutionalisation.

CONCLUSIONS

Apathy increases over the course of dementia and is associated with worse clinical outcomes independent of depression. Distinguishing apathy and depression appears important given their different implications for prognosis and management.

Detecting depression in persons living with mild cognitive impairment: a systematic review

OBJECTIVE

Depression is common in persons experiencing mild cognitive impairment (MCI), with 32% (95% Cl 27, 37) overall experiencing depression. Persons with MCI who have depression have more cognitive changes compared to those without depression. To understand how we can detect depressive symptoms in persons with MCI, we undertook a systematic review to identify tools that were validated compared with a reference standard.

DESIGN

We searched MEDLINE, EMBASE, PsycINFO, and Cochrane from inception to April 25, 2021, and conducted a gray literature search. Title/abstract and full-text screening were completed in duplicate. Demographic information, reference standards, prevalence, and diagnostic accuracy measures were then extracted from included articles (PROSPERO CRD: CRD42016052120).

RESULTS

Across databases, 8,748 abstracts were generated after removing duplicates. Six hundred and sixty-five records underwent full-text screening, with six articles included for data extraction. Nine tools were identified compared to a reference standard, with multiple demonstrating a sensitivity of 100% (Brief Assessment Schedule Depression Cards, Beck Depression Inventory-II, Cornell Scale for Depression in Dementia, Zung Self-Rated Depression Scale, and the Neuropsychiatric Inventory). The second highest sensitivity reported was 89% (Patient Health Questionnaire-9). Too few studies were available for a meta-analysis.

CONCLUSIONS

Multiple depression detection tools have been examined amongst MCI outpatients, with several showing high sensitivity. However, this evidence is only present in single studies, with little demonstration of how differing MCI types affect accuracy. More research is needed to confirm the accuracy of these tools amongst persons with MCI. At this time, several tools could be suitable for use in cognitive clinics.

Five Major Psychiatric Disorders and Alzheimer’s Disease: A Bidirectional Mendelian Randomization Study

Background: Extensive studies put forward the association between Alzheimer’s disease (AD) and psychiatric disorders; however, it remains unclear whether these associations are causal. Objective: We aimed to assess the potential causal relationship between major psychiatric disorders and AD. Methods: A bidirectional two-sample Mendelian randomization (MR) was applied to evaluate potential causality between five psychiatric disorders and AD by selecting the single-nucleotide polymorphisms from the genome-wide association studies as instrumental variables. Inverse-variance weighted (IVW) method was used as the main analyzing approach to estimate possible causal effects, alternative methods including MR-Egger, the MR pleiotropy residual sum and outlier, and leave-one-out analysis method were implemented as sensitivity analyzing approaches to ensure the robustness of results. Results: All forward and reverse MR analyses consistently suggested absent causal relations between psychiatric disorders and AD risk [forward IVW: ORADHD, 1.030, 95% CI, 0.908–1.168, p = 0.674; ORanxiety disorders, 0.904, 95% CI, 0.722–1.131, p = 0.377; ORASD, 0.973, 95% CI, 0.746–1.272, p = 0.846; ORBIP, 1.033, 95% CI, 0.925–1.153, p = 0.564; and ORschizophrenia, 1.039, 95% CI, 0.986–1.095, p = 0.156; reverse IVW: ORADHD, 0.993, 95% CI, 0.954–1.034, p = 0.746; ORanxiety disorders, 1.000, 95% CI, 0.999–1.000, p = 0.898; ORASD, 1.001, 95% CI, 0.962–1.042, p = 0.949; ORBIP, 0.997, 95% CI, 0.966–1.028, p = 0.831; and ORschizophrenia, 1.013, 95% CI, 0.978–1.051, p = 0.466]. Conclusion: There is no significant evidence supporting the causal association between the five major psychiatric disorders and AD.

Neuropsychiatric Profile as a Predictor of Cognitive Decline in Mild Cognitive Impairment

Introduction: Mild cognitive impairment is often associated with affective and other neuropsychiatric symptoms (NPS). This co-occurrence might have a relevant impact on disease progression, from MCI to dementia.

Objective: The aim of this study was to explore the trajectories of cognitive decline in an MCI sample from a memory clinic, taking into consideration a perspective of isolated cognitive functions and based on NPS clusters, accounting for the different comorbid symptoms collected at their baseline visit.

Methods: A total of 2,137 MCI patients were monitored over a 2.4-year period. Four clusters of NPS (i.e., Irritability, Apathy, Anxiety/Depression and Asymptomatic) were used to run linear mixed models to explore the interaction of cluster with time on cognitive trajectories using a comprehensive neuropsychological battery (NBACE) administered at baseline and at the three subsequent follow-ups.

Results: A significant interaction between cluster and time in cognitive decline was found when verbal learning and cued-recall were explored (p = 0.002 for both memory functions). For verbal learning, the Irritability cluster had the largest effect size (0.69), whereas the Asymptomatic cluster showed the smallest effect size (0.22). For cued-recall, the Irritability cluster had the largest effect size among groups (0.64), and Anxiety/Depression had the smallest effect size (0.21).

Conclusions: In MCI patients, the Irritability and Apathy NPS clusters shared similar patterns of worsening in memory functioning, which could point to these NPS as risk factors of a faster cognitive decline, acting as early prognostic markers and helping in the diagnostic process.

Impaired Cognitive Function is Associated with Motor Function and Activities of Daily Living in Mild to Moderate Alzheimer's Dementia

BACKGROUND

The deterioration of cognitive and motor functions and activities of daily living is common in Alzheimer's dementia.

OBJECTIVES

The purpose of this study was to investigate the correlation and the strength of the relationship between cognitive function and motor function and activities of daily living after a diagnosis of Alzheimer's disease dementia.

METHODS

Sixty-three patients with mild to moderate Alzheimer's disease dementia in a community setting of South Korea were examined for cognitive and motor functions, and functional levels. The test or measures used for cognitive function were the Mini-Mental State Examination (MMSE), Global Deterioration Scale (GDS), and Clinical Dementia Rating (CDR). The 10-meter walking test (10MWT), Berg Balance Scale (BBS), and Timed Up and Go Test (TUG) were used to examine motor function, while the Modified Barthel Index (MBI) and Katz Index (KI) were used to examining activities of daily living.

RESULTS

The MMSE had a positive correlation with that from the BBS (r=.338, p<.05), MBI (r=.363, p<.05), and KI (r=.276, p<.05). The GDS was negatively correlated with BBS (r=.319, p<.05). Multivariate regression analysis showed that MMSE was a major explanatory variable for BBS (R2 =.115, β=.338, p<.05) MBI (R2 =.131, β=.363, p<.05), and KI (R2 =.076, β=.276, p<.05).

CONCLUSION

The results of the present study show that cognitive function by MMSE is correlated with balance by BBS and activities of daily living by MBI and KI, and MMSE, which are tests or measures for cognitive function, can be explanatory variable to explain variations in the BBS, MBI, and KI in the persons with mild to moderate Alzheimer's dementia. It may mean that a decrease in cognitive function was found to affect motor function and activities of daily living. Based on this study, appropriate intervention approaches including physical exercise, should be considered for caring for persons with mild to moderate Alzheimer's dementia in a community setting.

Brain mechanisms underlying neuropsychiatric symptoms in Alzheimer's disease: a systematic review of symptom-general and -specific lesion patterns

Neuropsychiatric symptoms (NPSs) are common in patients with Alzheimer's disease (AD) and are associated with accelerated cognitive impairment and earlier deaths. This review aims to explore the neural pathogenesis of NPSs in AD and its association with the progression of AD. We first provide a literature overview on the onset times of NPSs. Different NPSs occur in different disease stages of AD, but most symptoms appear in the preclinical AD or mild cognitive impairment stage and develop progressively. Next, we describe symptom-general and -specific patterns of brain lesions. Generally, the anterior cingulate cortex is a commonly damaged region across all symptoms, and the prefrontal cortex, especially the orbitofrontal cortex, is also a critical region associated with most NPSs. In contrast, the anterior cingulate-subcortical circuit is specifically related to apathy in AD, the frontal-limbic circuit is related to depression, and the amygdala circuit is related to anxiety. Finally, we elucidate the associations between the NPSs and AD by combining the onset time with the neural basis of NPSs.

Correlation of Frontal Atrophy and CSF Tau Levels With Neuropsychiatric Symptoms in Patients With Cognitive Impairment: A Memory Clinic Experience

Background: Behavioral and psychological symptoms of dementia (BPSD) are a distressful condition. We aimed to investigate the BPSD distribution in subjects with cognitive impairment, and the potential correlations between BPSD and neurodegeneration in terms of cerebrospinal fluid (CSF) tau and brain atrophy.

Methods: One-hundred patients with mild cognitive impairment (MCI) or dementia (Alzheimer’s disease, AD; Lewy-body disease, LBD; frontotemporal dementia, FTD; vascular dementia, VD) underwent a complete diagnostic workup, including 3T-MRI and/or CT and CSF. Cortical atrophy was assessed with medial temporal atrophy (MTA), posterior atrophy (PA), and global cortical atrophy-frontal lobe (GCA-F) scales. BPSD were rated using the Neuropsychiatric Inventory (NPI), and BPSD clusters were defined according to the European Alzheimer Disease Consortium.

Results: Delusions, hallucinations, and psychosis cluster were differently distributed among the diagnostic groups (p < 0.05, p < 0.001, and p < 0.05), with LBD patients showing higher scores for hallucinations (vs. MCI, p < 0.001, and AD, p < 0.05) and psychosis cluster (vs. MCI, p < 0.05). In primary dementias, we found a negative correlation between NPI total score and tau levels (p = 0.08), confirmed by beta regression (p < 0.01), while a positive non-significant relationship was observed in MCI. Higher GCA-F scores were associated with delusions and apathy (p < 0.05, on both hemispheres) and hallucinations (left: p < 0.01, right: p < 0.05). GCA-F scores were positively correlated with psychosis cluster (right: p < 0.05), and agitation/aggression (left: p < 0.05). Conversely, nighttime disturbances were positively correlated with both GCA-F and MTA scores (left: p < 0.01; right: p < 0.05).

Conclusion: Our results suggest that psychotic symptoms are significantly more represented in LBD patients and that CSF tau and frontal atrophy are associated with the occurrence and severity of BPSD in clinical practice. Longitudinal studies are however required to ascertain their actual predictive value.

White matter hyperintensities and neuropsychiatric symptoms in mild cognitive impairment and Alzheimer's disease

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White matter hyperintensities play a larger role than grey matter atrophy in neuropsychiatric symptoms in AD/MCI.

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Greater white matter hyperintensities are related to lower grey matter volumes.

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Frontotemporal atrophy implicated in neuropsychiatric symptoms.

Neuropsychiatric symptoms (NPS), such as apathy, irritability and depression, are frequently encountered in patients with Alzheimer’s disease (AD). Focal grey matter atrophy has been linked to NPS development. Cerebrovascular disease is common among AD patients and can be detected on MRI as white matter hyperintensities (WMH). In this longitudinal study, the relative contribution of WMH burden and GM atrophy to NPS was evaluated in a cohort of mild cognitive impairment (MCI), AD and normal controls. This study included 121 AD, 315 MCI and 225 normal control subjects from the Alzheimer’s Disease Neuroimaging Initiative. NPS were assessed using the Neuropsychiatric Inventory and grouped into hyperactivity, psychosis, affective and apathy subsyndromes. WMH were measured using an automatic segmentation technique and mean deformation-based morphometry (DBM) was used to measure atrophy of grey matter regions. Linear mixed-effects models found focal grey matter atrophy and WMH volume both contributed significantly to NPS subsyndromes in MCI and AD subjects, however, WMH burden played a greater role. This study could provide a better understanding of the pathophysiology of NPS in AD and support the monitoring and control of vascular risk factors.

Minor and subthreshold depressive disorders in Alzheimer's disease: A systematic review and meta-analysis of prevalence studies

BACKGROUND

Depressive symptoms are common in Alzheimer's disease (AD) and negatively impact patient well-being. The main aim of the present study was to establish summary estimates for the prevalence of minor depressive disorder (MinD) and subthreshold depression in AD and synthesise evidence on prognosis and management of these symptoms in order to inform clinical guidelines.

METHODS

Systematic review and meta-analysis of cross-sectional and longitudinal studies of prevalence, prognosis, and treatments for minor and subthreshold depression in AD. We searched MEDLINE, Embase, PsycINFO and CINAHL. We included studies that reported prevalence of subthreshold depressive disorders and those reporting data on validity of diagnostic criteria, mechanisms, or randomised controlled clinical trials (RCTs) testing effectiveness of interventions. Estimates of prevalence were pooled using random-effects meta-analyses. Two authors screened articles and independently extracted data on study characteristics.

RESULTS

We reviewed 5671 abstracts, retrieved 621 full text articles and included a total of 15 studies. Pooling data from 10 studies showed that prevalence for MinD in AD was 22.0% (95% CI 16.0 to 28.0). Prevalence for a clinical diagnosis of MinD (DSM-III-R and DSM-IV) was 26.0% (95% CI 20.0 to 32.0; 6 studies). People with MinD experienced higher levels of neuropsychiatric symptoms, functional and cognitive decline, although studies remain cross-sectional. Neither sertraline nor a carer intervention were effective in reducing symptoms.

CONCLUSION

This review finds that MinD is prevalent in people with a diagnosis of AD and requires clinical attention. Research is warranted to develop effective interventions to treat and prevent these symptoms.

Depression, Anxiety, and Apathy in Mild Cognitive Impairment: Current Perspectives

Objective: Mild cognitive impairment (MCI) is an important risk state for dementia, particularly Alzheimer's disease (AD). Depression, anxiety, and apathy are commonly observed neuropsychiatric features in MCI, which have been linked to cognitive and functional decline in daily activities, as well as disease progression. Accordingly, the study's objective is to review the prevalence, neuropsychological characteristics, and conversion rates to dementia between MCI patients with and without depression, anxiety, and apathy. Methods: A PubMed search and critical review were performed relating to studies of MCI, depression, anxiety, and apathy. Results: MCI patients have a high prevalence of depression/anxiety/apathy; furthermore, patients with MCI and concomitant depression/anxiety/apathy have more pronounced cognitive deficits and progress more often to dementia than MCI patients without depression/anxiety/apathy. Conclusions and Implications: Depression, anxiety, and apathy are common in MCI and represent possible risk factors for cognitive decline and progression to dementia. Further studies are needed to better understand the role and neurobiology of depression, anxiety, and apathy in MCI.

Glucagon-like peptide-2 rescues memory impairments and neuropathological changes in a mouse model of dementia induced by the intracerebroventricular administration of streptozotocin

Glucagon-like peptide 2 (GLP-2) is derived from the proglucagon gene expressed in the intestines, pancreas and brain. Our previous study showed that GLP-2 improved lipopolysaccharide-induced memory impairments. The current study was designed to further investigated the potential of GLP-2 in memory impairment induced by intracerebroventricular administration of streptozotocin (ICV-STZ) in mice, which have been used as an animal model of sporadic Alzheimer’s disease (AD). STZ was administered on alternate days (Day-1 and Day-3) in order to induce dementia in male ddY mice. ICV-STZ-treated mice were administered GLP-2 (0.6 μg/mouse, ICV) for 5 days from 14 days after the first ICV administration of STZ. In these mice, we examined spatial working memory, the biochemical parameters of oxidative stress, or neurogenesis. The GLP-2 treatment restored spatial working memory in ICV-STZ-treated mice. ICV-STZ-treated mice showed markedly increased thiobarbituric acid reactive species (TBARS) and decreased glutathione (GSH) levels, and GLP-2 significantly restored these ICV-STZ-induced changes. GLP-2 also significantly restored neurogenesis in the subgranular zone of the dentate gyrus in ICV-STZ-treated mice. We herein demonstrated that GLP-2 significantly restored ICV-STZ-induced memory impairments as well as biochemical and histopathological alterations, and accordingly, propose that the memory restorative ability of GLP-2 is due to its potential to reduce oxidative stress.

Prevalence of delusions in drug-naïve Alzheimer disease patients: A meta-analysis

INTRODUCTION

Neuropsychiatric symptoms (NPS) are common at all stages of Alzheimer disease (AD). Delusions in AD are associated with negative clinical consequences and may signal rapid disease progression. Hence, we sought to determine the prevalence of delusions in drug-naïve (no cholinesterase inhibitor or neuroleptic medications) AD patients.

METHODS

In this meta-analysis, a search of the EMBASE, MEDLINE, and PsycINFO databases was performed. We selected studies reporting delusion prevalence measured by the Neuropsychiatric Inventory (NPI) in drug-naïve AD patients. An aggregate delusion event rate with 95% confidence interval (CI) was calculated. The I² statistic was used to assess the magnitude of between-study heterogeneity. Single variable meta-regressions allowed examination of the effect of moderating factors and heterogeneity. Quantitative measures were used to appraise for publication bias.

RESULTS

We identified 6 studies with 591 participants allowing calculation of the aggregate delusional prevalence rate. Irrespective of dementia severity, the aggregate event rate for delusions was 29.1% (95% CI: 20-41%; I²  = 84.59). No publication bias was observed.

CONCLUSION

This meta-analysis calculates a 29.1% prevalence rate of delusions in AD patients. There is a trend towards increasing delusion prevalence in concordance with increasing severity of dementia. Given delusions are associated with poorer outcomes, the obtained prevalence should motivate clinicians to screen carefully for delusions. Current literature limitations warrant future studies, with sub-analyses on dementia severity, and other neurobiological factors known to influence the presence of delusions.

Malnutrition is Associated with Behavioral and Psychiatric Symptoms of Dementia in Older Women with Mild Cognitive Impairment and Early-Stage Alzheimer's Disease

We examined the nutritional status and its association with behavioral psychiatric symptoms of dementia (BPSD) among 741 memory clinic patients (normal cognition (NC), 152; mild cognitive impairment (MCI), 271; early-stage Alzheimer disease (AD), 318). Nutritional status and BPSD were assessed using the Mini Nutritional Assessment Short-Form (MNA-SF) and the Dementia Behavior Disturbance Scale (DBD), respectively. Compared to subjects with NC, more subjects with MCI and early-stage AD were at risk of malnutrition (MNA-SF, 8-11: NC, 34.2%; MCI, 47.5%; early-stage AD, 53.8%) and were malnourished (MNA-SF, 0-7: NC, 4.6%; MCI, 5.9%; early-stage AD, 8.2%). Among patients with MCI or early-stage AD, those at risk of/with malnutrition showed higher DBD scores than those well-nourished (12.7 ± 9.0 vs. 9.5 ± 7.3; p < 0.001). Moreover, analysis of covariance adjusting for confounders showed that nutritional status was significantly associated with specific BPSD, including "verbal aggressiveness/emotional disinhibition" (F = 5.87, p = 0.016) and "apathy/memory impairment" (F = 15.38, p < 0.001), which were revealed by factor analysis of DBD. Our results suggest that malnutrition is common among older adults with mild cognitive decline, and possibility that nutritional problems are associated with individual BPSD.

The optimal treatment for improving cognitive function in elder people with mild cognitive impairment incorporating Bayesian network meta-analysis and systematic review

It's widely acknowledged that, as a neurodegenerative aging disease representing an intermediate stage between cognitive intactness and Alzheimer's disease (AD), Mild cognitive impairment (MCI) poses an excessive burden on patients' well-being, family members, health-care providers as well as the whole society. This study focuses on three cognitive interventions proposed by Clare and Woods, which are, Cognitive stimulation (CS), Cognitive training (CT) and Cognitive rehabilitation (CR). Our Network meta-analysis (NMA) aims to compar them with one another to determine the optimal cognitive intervention for elderly adults with MCI in improving their cognitive function. We applied extensive strategies to preliminary literature retrieval to identify relevant randomized controlled trials (RCTs) which scrupulously compared any two of the three cognitive interventions with one another or any one of the three with a control group as the placebo or non-active group in treating elder patients with MCI in accordance with Petersen's criteria. Our NMA of cognitive interventions for patients diagnosed with MCI appraised the relative effectiveness of cognitive interventions across trials simultaneously. Our study attempts to summarize available data to suggest that CS (Mean difference [MD] = 0.95, 95% confidence interval [CI]:0.27, 1.70) and CT (MD = 0.70, [CI]:0.11,1.30) were significantly beneficial to MCI patients for improving their cognition status while CR (MD = 0.59, [CI]:-0.30,1.50) scored lowest. Our study suggested CS was most likely to be the best intervention for improving the cognitive function of MCI patients.

Therapeutic efficacy of the Ginkgo special extract EGb761® within the framework of the mitochondrial cascade hypothesis of Alzheimer's disease

OBJECTIVES

The mitochondrial cascade hypothesis of dementia assumes mitochondrial dysfunction as an important common pathomechanism for the whole spectrum of age-associated memory disorders from cognitive symptoms in the elderly over mild cognitive impairment to Alzheimer's dementia. Thus, a drug such as the Ginkgo special extract EGb 761^® which improves mitochondrial function should be able to ameliorate cognitive deficits over the whole aging spectrum.

METHODS

We review the most relevant publications about effects of EGb 761^® on cognition and synaptic deficits in preclinical studies as well as on cognitive deficits in man from aging to dementia.

RESULTS

EGb 761^® improves mitochondrial dysfunction and cognitive impairment over the whole spectrum of age-associated cognitive disorders in relevant animal models and in vitro experiments, and also shows clinical efficacy in improving cognition over the whole range from aging to Alzheimer's or even vascular dementia.

CONCLUSIONS

EGb 761^® shows clinical efficacy in the treatment of cognitive deficits over the whole spectrum of age-associated memory disorders. Thus, EGb 761^® can serve as an important pharmacological argument for the mitochondrial cascade hypothesis of dementia.

The Games for Older Adults Active Life (GOAL) Project for People With Mild Cognitive Impairment and Vascular Cognitive Impairment: A Study Protocol for a Randomized Controlled Trial

Background: People living with Mild Cognitive Impairment (MCI) and Vascular Cognitive Impairment (VCI) are persons who do not fulfill a diagnosis of dementia, but who have a high risk of progressing to a dementia disorder. The most recent guidelines to counteract cognitive decline in MCI/VCI subjects suggest a multidimensional and multi-domain interventions combining cognitive, physical, and social activities. The purpose of this study is to test an innovative service that provides a multi-dimensional tele-rehabilitation program through a user-friendly web application. The latter has been developed through a participatory design involving MCI specialists, patients, and their caregivers. Particularly, the proposed tele-rehabilitation program includes cognitive, physical, and caregiver-supported social activities. The goal is to promote and preserve an active life style and counteract cognitive decline in people living with MCI/VCI. Methods:The study is a randomized controlled trial. Sixty subjects will be randomly assigned to the experimental group, who will receive the tele-rehabilitation program, or the control group, who will not receive any treatment. The trial protocol comprises three steps of assessment for the experimental group: at the baseline (T_0), after tele-rehabilitation program (T_1) and at follow-up after 12-months (T_2). Differently, the control group will be assessed twice: at the baseline and at 12-months follow-up. Both the experimental and the control group will be assessed with a multidimensional evaluation battery, including cognitive functioning, behavioral, functional, and quality of life measures. The tele-rehabilitation program lasts 8 weeks and includes cognitive exercises 3 days a week, physical activities 2 days a week, and social activities once a week. In addition, group will be given an actigraph (GENEActiv, Activisinghts Ltd., Cambridgshire, UK) to track physical and sleep activity. Discussion:Results of this study will inform on the efficacy of the proposed tele-rehabilitation to prevent or delay further cognitive decline in MCI/VCI subjects. The expected outcome is to counteract cognitive decline and improve both physical functioning and quality of life. Ethics and Dissemination:The study is approved by the Local Ethics Committee and registered in https://clinicaltrials.gov (NCT03383549). Dissemination will include submission to a peer-reviewed journal, patients, and healthcare magazines and congress presentations. Trial Registration: ClinicalTrials.gov ID: NCT03383549 (registration date: 26/dec/2017) Trial Funding: Bando FAS Salute 2014 Regione Toscana Version Identifier: ver 5-16/11/2018.

Effects of creative expression therapy on Chinese elderly patients with dementia: an exploratory randomized controlled trial

Purpose: This study aimed to evaluate the effect of creative expression (CE) therapy on cognition, communication, emotion, and quality-of-life in people with dementia. Methods: One hundred individuals were included in this study, of whom 91 completed the study (mean age=84.33). The participants were randomly assigned to an intervention group (n=43) and a control group (n=48), and received the CE program or standard cognitive (SC) training twice a week for 6 weeks, respectively. Both groups were submitted to extensive neuropsychological tests, as follows - Mini-Mental State Examination (MMSE), Quality of Life-Alzheimer's Disease (QOL-AD), Cornell Scale for Depression in Dementia (CSDD), Functional Assessment of Communication Skills (FACS) at baseline, 1-, and 4 -weeks post-intervention, and the Observed Emotion Rating Scale (OERS) was measured during the intervention period at weeks 3 and 6. Results: The participants demonstrated significant improvements in cognitive function, quality-of-life, depression degree, communication ability, and emotion status (P<0.05) at post-intervention, which were maintained at 1-month follow-up. Conclusion: This study provides preliminary evidence that CE therapy developed in the study benefits elderly Chinese with dementia. The findings indicated that non-pharmacological intervention programs - CE therapy - can be applied in the management of neuropsychiatric symptoms of dementia.

Examining differences in neuropsychiatric symptom factor trajectories in empirically derived mild cognitive impairment subtypes

OBJECTIVE

The aim of this study was to examine neuropsychiatric symptom (NPS) factor severity progression over time in empirically derived (ED) mild cognitive impairment (MCI) subtypes.

METHODS

Participants in the Alzheimer's Disease Neuroimaging Initiative study diagnosed with MCI by Alzheimer's Disease Neuroimaging Initiative protocol using conventional clinical (CC) criteria (n = 788) were reclassified using cluster analysis as amnestic, dysnomic, dysexecutive MCI, or cluster-derived normal (CC-Normal) using empirical criteria. Cognitively normal (CN) participants (n = 207) were also identified. The Neuropsychiatric Inventory-Questionnaire (NPI-Q) was administered from baseline through 48-month follow-up. Exploratory factor analysis was completed to determine the NPI-Q factor structure at 6-month follow-up. Multilevel modeling was used to determine NPI-Q symptom severity factor and apathy symptom progression over time by cognitive subtype.

RESULTS

The exploratory factor analysis revealed that the NPI-Q consisted of 2 factors: hyperactivity/agitation and mood symptoms. Using clinical and empirical criteria, all MCI groups were identified as having more severe hyperactivity/agitation symptoms than CN participants. However, only the amnestic MCI group identified using empirical criteria showed an increase in symptom severity over time relative to CN participants. Mood factor and apathy symptoms were found to be more severe in dysexecutive and amnestic groups in both models. Similarly, both models identified a significant worsening of mood and apathy symptoms over time for dysexecutive and amnestic groups relative to CN participants.

CONCLUSIONS

This study provides further support that empirical criteria aid in examining the progression of clinical characteristics associated with MCI. Further, it helps to identify which MCI subtypes may be at higher risk for NPS progression.

Sleep Disturbance in Mild Cognitive Impairment and Association With Cognitive Functioning. A Case-Control Study

Objectives: The aims of the current study are to (1) report the frequency of specific sleep disturbance symptoms in Mild Cognitive Impairment (MCI) and cognitive healthy older persons; (2) examine whether overall poor sleep and specific sleep disturbance symptoms are more common in persons with MCI compared to cognitive healthy older controls and; (3) examine the association between sleep disturbances and performance in general and specific cognitive domains in persons with MCI and separately in cognitive healthy older persons.

Methods: Data were collected at the Fondazione Ospedale San Camillo Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Venice, Italy as part of the European VPH-DARE@IT project. We included 69 persons with MCI (mean age 75.7; SD = 7.7) and 72 sex-matched cognitively healthy controls (mean age 71.8; SD = 7.0). Participants underwent extensive neuropsychological assessment and evaluation of subjective sleep performance with the Sleep Continuity in Alzheimer’s Disease Scale(SCADS).

Results: A fifth of MCI patients (21.7%, n = 15) had poor sleep compared to 15.3% (n = 11) of cognitively healthy controls. MCI patients had a 3.2 higher odds of having poor sleep compared to cognitively healthy controls after adjustment for age, education, sex, and general cognitive functioning (Odds Ratio (OR) = 3.2; 95% Confidence Interval (CI) = 1.1–9.2). Persons who reported waking up twice or more during the night had higher odds of being MCI compared to those who never wake or wake only once (OR = 2.6; 95% CI = 1.1–6.1). In MCI patients, poor sleep was associated with better general cognitive functioning and short-term working memory, whereas in cognitive healthy older persons poor sleep was associated with impairment in episodic memory performance and executive functioning.

Discussion: Our results confirm previous studies showing that sleep disturbances are common in MCI, and this may be due to an ongoing neurodegenerative process rather than a symptom of cognitive impairment. Future research with objective sleep measurements are needed in MCI as well as interventions to improve sleep with the aim of preventing cognitive decline.

Identification of the optimal cognitive drugs among Alzheimer's disease: a Bayesian meta-analytic review

PURPOSE

The increasing prevalence of Alzheimer's disease (AD) demands more effective drugs, which are still unclear. The aim of this study is to compare the effectiveness of six drugs, such as donepezil, rivastigmine, galantamine, memantine, huperzine-A, and tacrine, in senior AD patients and identify the most effective one to improve patients' cognitive function.

METHODS

A system of search strategies was used to identify relevant studies including randomized controlled trials and clinical controlled trials evaluating the efficacy of six drugs in patients with AD. We updated relevant studies that were published before March 2018 as full-text articles. Using Bayesian network meta-analysis (NMA), we ranked cognitive ability objectively based on Mini-Mental State Examination (MMSE). Pairwise and NMAs were sequentially performed for the efficacy of drugs compared to each drug or control group through the trials included.

RESULTS

Among the 35 trials included, no obvious heterogeneity (I 2=0.0%, P=0.583) was revealed according to the pooled data for cognition in NMA and the mean difference (MD) of memantine (MD=1.7, 95% CI: 0.73, 2.8) showed that the memantine was significantly efficacious in the treatment group in terms of MMSE. Followed by galantamine, huperzine-A, rivastigmine, tacrine, and donepezil.

CONCLUSION

As the first NMA comparing the major drugs in market for AD, our study suggests that memantine might have a more significant benefit on cognition than other five drugs available.

Investigation of possible risk factors for depression in Alzheimer's disease: A systematic review of the evidence

BACKGROUND

Depression is common in people with Alzheimer's disease (AD), and is associated with increased risk of institutionalization and mortality. Understanding risk factors for depression in AD is key to its development and treatment.

METHODS

We searched the MEDLINE, EMBASE, PsycINFO, and CINAL databases for longitudinal prospective cohort studies that evaluated risk factors for depression in people with AD. Two authors independently selected articles for inclusion and assessed quality of studies using predetermined criteria.

RESULTS

In seven studies that met the inclusion criteria, 2029 participants were followed up for a median of 5 years. Gender and educational attainment were not predictors of depression risk. History of a past psychiatric disorder and greater cognitive impairment predicted increased risk of depression in more than one study. In single studies, younger age, having a family history of psychiatric disorder, neuroticism, functional decline, presence of sleep disturbance and aggression, and increased cardiovascular risk predicted depression risk. Not being within 6 months of dementia onset and, counterintuitively having two comorbid disorders were protective factors in one study.

LIMITATIONS

A small number of studies exist overall and only a few have examined the same risk factors. Most of the studies have measured depression using scales that are not validated in AD.

CONCLUSIONS

These results inform a preliminary model of depression risk in people with AD. Unlike in the general population, men and women and those with higher and lower educational levels of attainment may be equally at risk of depression. Clinicians should be aware of these possible differences in the risk profile for depression in AD populations, to assist detection and enable early treatment. Interventions to delay cognitive and functional decline may reduce depression risk.

Prevalence of anxiety in patients with mild cognitive impairment: A systematic review and meta-analysis

BACKGROUND

Prevalence rates of anxiety in patients with mild cognitive impairment (MCI) varied widely across studies and may confer a higher likelihood of progression to dementia. Our aim was to estimate the prevalence of anxiety in MCI and identify reasons for heterogeneity in the reported results.

METHODS

A computerized search in PubMed, EMBASE, and Psyc INFO for studies on anxiety in MCI was performed up to March 2017. The overall prevalence of anxiety in patients with MCI was pooled using a random-effects model. Heterogeneity was explored using stratification (recruitment resource; method of anxiety diagnosis; method of MCI diagnosis; and region) and random-effects meta-regression.

RESULTS

Of 2494 unique abstracts, 290 were selected for full-text review, and 39 studies, representing 10,587 patients, met all inclusion criteria. The overall pooled prevalence of depression in patients with MCI was 21.0% (95% CI, 16.2-26.7) with significant heterogeneity present (I² = 97.2%, p < 0.001). When stratified by source, the prevalence of anxiety in patients with MCI in community-based samples was 14.3% (95% CI, 9.7-20.5) and was 31.2% (95% CI, 23.6-40.0) in clinic-based samples, which was significantly different (p < 0.01). The prevalence of anxiety estimates also differed significantly, when stratification by the method of anxiety diagnosis (p < 0.01). However, the criteria used for MCI diagnosis and geographical region did not significantly influence the prevalence estimate.

LIMITATIONS

We did not consider the usage of anti-anxiety drugs and language bias.

CONCLUSIONS

The prevalence of anxiety in patients with MCI was common and variability in prevalence of anxiety across studies can be attributed partly to the source of the sample and method of anxiety diagnosis. Further research is needed to identify sources of heterogeneity.

Mitochondrial Pharmacology of Dimebon (Latrepirdine) Calls for a New Look at its Possible Therapeutic Potential in Alzheimer's Disease

Dimebon (latrepirdine), an old antihistaminic drug, showed divergent results in two large clinical trials in Alzheimer disease (AD), which according to our review might be related to the specific pharmacological properties of the drug and the different patient populations included in both studies. Out of the many pharmacological effects of Dimebon, improvement of impaired mitochondrial function seeems to be most relevant for the substantial effects on cognition and behaviour reported in one of the studies, as these effects are already present at the low concentrations of dimebon measured in plasma and tissues of patients and experimental animals. Since impaired mitochondrial function seems to be the major driving force for the progression of the clinical symptoms and since most of the clinical benefits of dimebon originate from an effect on the symptomatic deterioration, mitochondrial improvement can also explain the lack of efficacy of this drug in another clinical trial where symptoms of the patiets remained stable for the time of the study. Accordingly, it seems worthwhile to reevaluate the clinical data to proof that clinical response is correlated with high levels of Neuropsychiatric Symptoms as these show a good relationship to the individual speed of symptomatic decline in AD patients related to mitochondrial dysfunction.

Factors affecting the appetites of persons with Alzheimer's disease and mild cognitive impairment

AIM

Appetite loss has been associated with Alzheimer's disease (AD) and mild cognitive impairment (MCI). Among older people, decreased appetite can result in poor nutrition and subsequent loss of independent living. We examined the factors related to appetite loss in persons with AD and MCI to provide evidence for countermeasures to prevent appetite loss and progression of cognitive impairment.

METHODS

We included 1238 older adults undergoing outpatient treatment at the Center for Comprehensive Care and Research on Memory Disorders (Medical Center for Dementia) at the National Center for Geriatrics and Gerontology in Obu, Japan. The Council on Nutrition Appetite Questionnaire, an appetite questionnaire for older people, was used to evaluate appetite. Appetite loss in persons diagnosed with AD or MCI was divided into two groups according to the Council on Nutrition Appetite Questionnaire scores, and logistic regression analysis was carried out to identify independent factors associated with appetite loss. The following variables were used to evaluate for covariates: general information, functional evaluation and medications.

RESULTS

The AD and MCI groups contained 853 and 385 individuals, respectively. In both groups, depression and difficulty in maintaining attention while eating were significantly associated with poor appetite. Among persons with AD, lower vitality, more comorbidities, non-use of antidementia drugs and use of psychotropic drugs were also significantly associated with poor appetite.

CONCLUSIONS

The present study recognized possible factors individually associated with appetite loss among persons with AD or MCI. Future studies are required to examine supportive strategies to treat poor appetite in these populations. Geriatr Gerontol Int 2018; 18: 1236-1243.

Comparison of multiple interventions for older adults with Alzheimer disease or mild cognitive impairment: A PRISMA-compliant network meta-analysis

BACKGROUND

The increasing prevalence of Alzheimer disease (AD) emphasizes the need for effective treatments. Both pharmacological therapies such as nutrition therapy (NT) and nonpharmacologic therapies including traditional treatment or personalized treatment (e.g., physical exercise, music therapy, computerized cognitive training) have been approved for the treatment of AD or mild cognitive impairment (MCI) in numerous areas.

METHODS

The aim of this study was to compare 4 types of interventions, physical exercise (PE), music therapy (MT), computerized cognitive training (CCT), and NT, in older adults with mild to moderate AD or MCI and identify the most effective intervention for their cognitive function. We used a system of search strategies to identify relevant studies and include randomized controlled trials (RCTs), placebo-controlled trials evaluating the efficacy and safety of 4 interventions in patients with AD or MCI. We updated the relevant studies which were published before March 2017 as a full-text article. Using Bayesian network meta-analysis (NMA), we ranked cognitive ability based objectively on Mini-Mental State Examination (MMSE), and assessed neuropsychiatric symptoms based on Neuropsychiatric Inventory (NPI). Pairwise and network meta-analyses were sequentially performed for efficacy and safety of intervention compared to control group through RCTs included.

RESULTS

We included 17 RCTs. Fifteen trials (n = 1747) were pooled for cognition and no obvious heterogeneity was found (I = 21.7%, P = .212) in NMA, the mean difference (MD) of PE (MD = 2.1, confidence interval [CI]: 0.44-3.8) revealed that PE was significantly efficacious in the treatment group in terms of MMSE. Five trials (n = 660) assessed neuropsychiatric symptoms with an obvious heterogeneity (I = 61.6%, P = .034), the MD of CCT (MD = -7.7, CI: -14 to -2.4), revealing that CCT was significantly efficacious in NPI.

CONCLUSIONS

As the first NMA comparing different interventions for AD and MCI, our study suggests that PE and CCT might have a significant improvement in cognition and neuropsychiatric symptoms respectively. Moreover, nonpharmacological therapies might be better than pharmacological therapies.

Lower Choline and Myo-Inositol in Temporo-Parietal Cortex Is Associated With Apathy in Amnestic MCI

Apathy is a common symptom in patients with amnestic mild cognitive impairment (aMCI) and is associated with an increased risk of progression to Alzheimer's disease (AD). The neural substrates underlying apathy in aMCI may involve multiple brain regions, including the anterior cingulate cortex and the temporo-parietal region. Here we investigated neurometabolites in brain regions that may underlie apathy in aMCI patients using proton magnetic resonance spectroscopy (¹H-MRS). Twenty-eight aMCI patients with varying degrees of apathy and 20 matched controls underwent ¹H-MRS. Spectra were acquired from single voxels in the posterior cingulate cortex (PCC), dorsal anterior cingulate cortex (DACC), right dorsolateral prefrontal cortex (DLPFC), and right temporo-parietal cortex (TPC). Apathy was measured with the Apathy Evaluation Scale (AES). Spearman partial correlations between metabolite concentrations in each region and severity of apathy were determined. Additionally, analyses of covariance (ANCOVA) were performed to determine whether metabolite changes differed between patients with or without clinically-diagnosed apathy. The degree of apathy was found to be negatively correlated with choline and myo-inositol (mI) in the TPC. Additional exploratory analyses suggested that N-acetylaspartate (NAA)/mI ratio was reduced in aMCI without clinical apathy but not in aMCI with clinical apathy. In the DACC, glutamate and glutamine (Glx) levels tended to be higher in the aMCI with apathy group compared to controls and reduced in association with depression scores. In conclusion, apathy in aMCI patients was associated with neurometabolite changes indicative of altered membranal integrity and glial function in the right TPC. Findings also indicated that in a clinically-diagnosed aMCI cohort, apathy symptoms may be suggestive of neural changes that are distinct from aMCI without apathy.

State of the Science: Apathy As a Model for Investigating Behavioral and Psychological Symptoms in Dementia

Apathy is one of the most common and pervasive of the behavioral and psychological symptoms of dementia (BPSDs). Apathy has profound consequences for morbidity, mortality, and caregiver burden. Treatment of apathy has been hindered because of poor understanding of the mechanisms underlying this heterogeneous syndrome. Research has demonstrated that apathy is associated with disruption of the frontal-striatal system in individuals with neurodegenerative disease. As with other BPSDs, these neural mechanisms alone do not completely account for the syndrome; individual, caregiver, and environmental factors also contribute to apathy. In this article, we modify a current conceptual model of the factors contributing to BPSDs to examine determinants of apathy. This integrative model provides a more complete and theoretically informed understanding of apathy, allowing for greater insight into potential targets for research, intervention, and care. We end by proposing an agenda for moving the science of BPSDs in general, and apathy in particular, forward.

Amyloid burden and incident depressive symptoms in preclinical Alzheimer's disease

BACKGROUND

Relationships between depression and Alzheimer's disease (AD) may become clearer if studied in preclinical AD where dementia is not present.

METHOD

The aim of this study was to evaluate prospectively, relationships between brain amyloid-β (Aβ), depressive symptoms and screen positive depression in cognitively normal (CN) older adults. Depressive symptoms were measured with the Geriatric Depression Inventory (GDS-15) in CN adults from the Australian Imaging Biomarkers and Lifestyle (AIBL) study without depression at baseline and classified as having abnormally high (Aβ+; n = 136) or low (Aβ-; n = 449) Aβ according to positron emission tomography at 18-month intervals over 72 months.

RESULTS

Incident cases of screen positive depression were not increased in Aβ+ CN adults although small increases in overall depressive symptoms severity (d = - 0.25; 95% CI, - 0.45, - 0.05) and apathy-anxiety symptoms (d = - 0.28; 95% CI - 0.48, - 0.08) were.

LIMITATIONS

As the AIBL sample is an experimental sample, no individuals had severe medical illnesses or significant psychiatric disorders. Additionally, individuals who had evidence of screen-positive depression at screening were excluded from enrolment in the AIBL study. Thus, the current data can be considered only as providing a foundation for understanding relationships between Aβ and depression in preclinical AD.

CONCLUSIONS

These results suggest that the presence of a depressive disorder or even increased depressive symptoms are themselves unlikely to be a direct consequence of increasing Aβ. New depressive disorders presenting in CN older adults could therefore be investigated for aetiologies beyond AD.

Protective preparation: a process central to family caregivers of persons with mild cognitive impairment

ABSTRACTBackground:To develop a theoretical model explaining the longitudinal changes in the caregiving process for family caregivers of persons with mild cognitive impairment (MCI) in Taiwan.

METHODS

A longitudinal, grounded theory approach using in-depth face-to-face interviews and an open-ended interview guide. We conducted 42 interviews over a two-year period; each participant was interviewed at least once every six months. All participants were interviewed in their home. The participants total of 13 family caregivers of persons with MCI.

RESULTS

One core theme emerged: "protective preparation." This reflected the family caregiving process of preparation for a further decline in cognitive function, and protection from the impact of low self-esteem, accidents, and symptoms of comorbidities for the family member with MCI. Protective preparation contained three components: ambivalent normalization, vigilant preparation, and protective management.

CONCLUSIONS

Interventions to help family caregivers manage the changes in persons with MCI can reduce caregiver burden. Our findings could provide a knowledge base for use by healthcare providers to develop and implement strategies to reduce caregiver burden for family caregivers of persons with MCI.

Prevalence, neurobiology, and treatments for apathy in prodromal dementia

BACKGROUND

Apathy, characterized by diminished motivation, is a highly prevalent neuropsychiatric symptom in dementia. However, there is a substantial knowledge gap with regard to prevalence rates, neurobiological underpinnings, and effective treatments for apathy in pre-dementia states, including mild cognitive impairment (MCI) and mild behavioral impairment (MBI).

METHODS

We conducted a comprehensive literature search using MEDLINE, Embase, and PsycINFO databases to identify available research on apathy in prodromal dementia.

RESULTS

Apathy has consistently been detected in individuals with MCI with varying prevalence rates, and only recently has literature discussed the prevalence of apathy in MBI. Few pharmacological treatments have been utilized for apathy, with galantamine and risperidone showing mild reductions in apathetic behaviors. Non-pharmacological interventions in prodromal dementia are beginning to be explored and show promise, but few studies have replicated those results.

DISCUSSION

More comprehensive guidelines for diagnosing apathy and further research investigating neurobiological mechanisms of apathy in MCI and MBI are required in order to effectively treat apathetic patients in prodromal dementia.

Neuropsychiatric symptoms as risk factors of dementia in a Mexican population: A 10/66 Dementia Research Group study

Introduction

Cognitive and/or memory impairment are the main clinical markers currently used to identify subjects at risk of developing dementia. This study aimed to explore the relationship between the presence of neuropsychiatric symptoms and dementia incidence.

Methods

We analyzed the association between neuropsychiatric symptoms and incident dementia in a cohort of 1355 Mexican older adults from the general population over 3 years of follow-up, modeling cumulative incidence ratios using Poisson models.

Results

Five neuropsychiatric symptoms were associated with incident dementia: delusions, hallucinations, anxiety, aberrant motor behavior, and depression. The simultaneous presence of two symptoms had a relative risk, adjusted for mild cognitive impairment, diabetes, indicators of cognitive function, and sociodemographic factors, of 1.9 (95% confidence interval, 1.2–2.9), whereas the presence of three to five, similarly adjusted, had a relative risk of 3.0 (95% confidence interval, 1.9–4.8).

Discussion

Neuropsychiatric symptoms are common in predementia states and may independently contribute as risk factors for developing dementia.

•

Not only cognitive impairment and cognitive features are useful in identifying older adults at risk for developing dementia.

•

Of the 12 neuropsychiatric symptoms evaluated, 5 were associated with incident dementia (delusions, hallucinations, depression, anxiety, and aberrant motor behavior) in a 3-year follow-up.

•

The evaluation of neuropsychiatric symptoms, along with other simple, practical, and inexpensive features, may be useful in identifying subjects at risk of dementia in community health settings and by general practitioners.

Signs and symptoms preceding the diagnosis of Alzheimer's disease: a systematic scoping review of literature from 1937 to 2016

OBJECTIVE

Late diagnosis of Alzheimer's disease (AD) may be due to diagnostic uncertainties. We aimed to determine the sequence and timing of the appearance of established early signs and symptoms in people who are subsequently diagnosed with AD.

METHODS

We used systematic review methodology to investigate the existing literature. Articles were reviewed in May 2016, using the following databases: MEDLINE, PsycINFO, CINAHL, British Nursing Index, PubMed central and the Cochrane library, with no language restriction. Data from the included articles were extracted independently by two authors and quality assessment was undertaken with the quality assessment and diagnostic accuracy tool-2 (QUADAS tool-2 quality assessment tool).

RESULTS

We found that depression and cognitive impairment were the first symptoms to appear in 98.5% and 99.1% of individuals in a study with late-onset AD (LOAD) and 9% and 80%, respectively, in early-onset AD (EOAD). Memory loss presented early and was experienced 12 years before the clinically defined AD dementia in the LOAD. However, the rapidly progressive late-onset AD presented predominantly with 35 non-established focal symptoms and signs including myoclonus (75%), disturbed gait (66%) and rigidity. These were misdiagnosed as symptoms of Creutzfeldt-Jacob disease (CJD) in all the cases. The participant with the lowest mini-mental state examination score of 25 remained stable for 2 years, which is consistent with the score of the healthy family members.

CONCLUSIONS

The findings of this review suggest that neurological and depressive behaviours are an early occurrence in EOAD with depressive and cognitive symptoms in the measure of semantic memory and conceptual formation in LOAD. Misdiagnosis of rapidly progressive AD as CJD and the familial memory score can be confounding factors while establishing a diagnosis. However, the study was limited by the fact that each one of the findings was based on a single study.

Type A monoamine oxidase and serotonin are coordinately involved in depressive disorders: from neurotransmitter imbalance to impaired neurogenesis

Type A monoamine oxidase (MAOA) catabolizes monoamine transmitters, serotonin, norepinephrine and dopamine, and plays a major role in the onset, progression and therapy of neuropsychiatric disorders. In depressive disorders, increase in MAOA expression and decrease in brain levels of serotonin and norepinephrine are proposed as the major pathogenic factors. The functional polymorphism of MAOA gene and genes in serotonin signal pathway are associated with depression. This review presents recent advance in studies on the role of MAOA in major depressive disorder and related emotional disorders. MAOA and serotonin regulate the prenatal development and postnatal maintenance of brain architecture and neurocircuit, as shown by MAOA-deficient humans and MAO knockout animal models. Impaired neurogenesis in the mature hippocampus has been proposed as "adult neurogenesis" hypothesis of depression. MAOA modulates the sensitivity to stress in the stages of brain development and maturation, and the interaction of gene-environmental factors in the early stage regulates the onset of depressive behaviors in adulthood. Vice versa environmental factors affect MAOA expression by epigenetic regulation. MAO inhibitors not only restore compromised neurotransmitters, but also protect neurons from cell death in depression through induction of anti-apoptotic Bcl-2 and prosurvival neurotrophic factors, especially brain-derived neurotrophic factor, the deficiency of which is detected in depression. This review discusses novel role of MAOA and serotonin in the pathogenesis and therapy of depressive disorders.

Music therapy is a potential intervention for cognition of Alzheimer's Disease: a mini-review

Alzheimer's Disease (AD) is a global health issue given the increasing prevalence rate and the limitations of drug effects. As a consequent, non-pharmacological interventions are of importance. Music therapy (MT) is a non-pharmacological way with a long history of use and a fine usability for dementia patients. In this review, we will summarize different techniques, diverse clinical trials, and the mechanisms of MT as it is helpful to the cognition in AD, providing reference for future research. Many articles have demonstrated that MT can reduce cognitive decline especially in autobiographical and episodic memories, psychomotor speed, executive function domains, and global cognition. MT is a promising intervention for strategy of dementia especially of AD and it must be started as early as possible. However, more evidences with prospective, randomized, blinded, uniform and rigorous methodological investigations are needed. And we should consider to combine MT with other cognitive stimulations such as dance, physical exercise, video game, art and so on.

Physical Activity in Community Dwelling Older People: A Systematic Review of Reviews of Interventions and Context

BACKGROUND

The promotion and maintenance of higher physical activity (PA) levels in the older population is an imperative for cognitive and healthy ageing but it is unclear what approaches are best suited to achieve this for the increasing number of older people living in the community. Effective policies should be informed by robust, multi-disciplinary and multi-dimensional evidence, which not only seeks what works, but in 'what context? In addition to evidence on the efficacy and effectiveness of PA for maintaining cognitive health, social contexts such as 'how do we actually get older people to partake in PA?' and 'how do we sustain that activity long-term?' also need highlighting. This review is part of a comprehensive evidence synthesis of preventive interventions in older age, with a focus on healthy behaviours to identify evidence gaps and inform policy relating to ageing well and cognitive health. An overview of systematic reviews of PA was conducted to explore three topics: (1) PA efficacy or effectiveness for primary prevention of cognitive decline in 55+; (2) Interventions efficacious or effective for increasing PA uptake and maintenance in 55+; (3) barriers and facilitators to PA in 55+.

METHODS

Multiple databases were searched for studies in English from OECD countries between 2000 and 2016. Quality of included reviews in questions (1) and (2) were assessed using AMSTAR. Review protocols were registered on PROSPERO (CRD42014015554, 42014015584, CRD42014015557) and reviews follow PRISMA guideline.

FINDINGS

Overall, 40 systematic reviews were included. Question 1 (n = 14). 8,360 participants. Evidence suggests that PA confer mild positive effects on cognition in older adults with and without previous cognitive impairment. However, there is insufficient evidence of a dose-response relationship. Evidence on the effects of PA on delay of dementia onset is inconclusive. Question 2 (n = 17). 79,650 participants. Evidence supports the effectiveness of a variety of interventions, including group delivered, centre-based and cognitive approaches on short-term uptake of PA behaviour. Question 3 (n = 9). 22,413 participants. Barriers include health status, previous PA habits and experiences, and cultural sensitivity, while facilitators include enjoyable activities and convenient scheduling.

CONCLUSION

PA can offer small benefits to brain health, but evidence on how much activity is required to produce this effect is lacking. Evidence on the effectiveness of PA for preventing dementia and cognitive decline is lacking. Behavioural (walking, exercise) and cognitive (counselling and motivational interviews) interventions are effective for short-term uptake of physical activity in older people. In order to maintain long-term participation in PA, individualised interventions modelled using behavioural theories may be required. Public health messages should be aimed at promoting acceptable levels of PA above normal daily activities in older people. Policy and strategies aimed at increasing PA in older people should be encouraged while considering barriers and facilitators to behaviour change.

Clinicopathological correlates of depression in early Alzheimer's disease in the NACC

OBJECTIVE

Depression may be a prodrome to Alzheimer's disease (AD). We assessed whether AD neuropathology is associated with depression in mild cognitive impairment (MCI) and mild dementia (dAD).

METHODS

All clinical and neuropathological data for this study came from the National Alzheimer's Coordinating Center (NACC). Healthy control (HC, n = 120), MCI (n = 77), and mild dAD (n = 93) patients who underwent brain autopsy were included. In regression models with Geriatric Depression Scale (GDS) as the outcome, neuritic plaque (NP) score or Braak Stages of neurofibrillary (NF) pathology were covariates.

RESULTS

GDS was not associated with cognitive status, NP score, Braak Stages, or their interaction. In both models, a history of TIAs, depression within the last 2 years, current benzodiazepine use, and greater severity of neuropsychiatric symptoms were associated with greater depression. In the Braak Stages model, less education was another significant predictor.

CONCLUSIONS

Depression in early AD appears to be independent of NP and NF pathology. Studies are needed to investigate other mechanisms that may be responsible for depression in MCI and dAD.