Impact of socioeconomic status on initial clinical presentation to a memory disorders clinic

Healthcare use according to deprivation among French Alzheimer's Disease and Related Diseases subjects: a national cross-sectional descriptive study based on the FRA-DEM cohort

Introduction

Pluriprofessional and coordinated healthcare use is recommended for Alzheimer's Disease and Related Diseases (ADRD). Despite a protective health system, France is characterized by persistent and significant social inequalities in health. Although social health inequalities are well documented, less is known about social disparities in healthcare use in ADRD, especially in France. Therefore, this study aimed to describe healthcare use according to socioeconomic deprivation among ADRD subjects and the possible potentiating role of deprivation by age.

Methods

We studied subjects identified with incident ADRD in 2017 in the French health insurance database (SNDS). We described a large extent of their healthcare use during the year following their ADRD identification. Deprivation was assessed through French deprivation index (Fdep), measured at the municipality level, and categorized into quintiles. We compared healthcare use according to the Fdep quintiles through chi-square tests. We stratified the description of certain healthcare uses by age groups (40-64 years, 65-74 years, 75-84 years, 85 years, and older), number of comorbidities (0, 1, 2-3, 4 comorbidities and more), or the presence of psychiatric comorbidity.

Results

In total, 124,441 subjects were included. The most deprived subjects had less use of physiotherapy (28.56% vs. 38.24%), ambulatory specialists (27.24% vs. 34.07%), ambulatory speech therapy (6.35% vs. 16.64%), preventive consultations (62.34% vs. 69.65%), and were less institutionalized (28.09% vs. 31.33%) than the less deprived ones. Conversely, they were more exposed to antipsychotics (11.16% vs. 8.43%), benzodiazepines (24.34% vs. 19.07%), hospital emergency care (63.84% vs. 57.57%), and potentially avoidable hospitalizations (12.04% vs. 10.95%) than the less deprived ones.

Discussion and conclusion

The healthcare use of subjects with ADRD in France differed according to the deprivation index, suggesting potential health renunciation as in other diseases. These social inequalities may be driven by financial barriers and lower education levels, which contribute to health literacy (especially for preventive care). Further studies may explore them.

Socioeconomic Status and Dementia Risk Among Intensive Care Unit Survivors: Using National Health Insurance Cohort in Korea

BACKGROUND

In aging populations, more elderly patients are going to the intensive care unit (ICU) and surviving. However, the specific factors influencing the occurrence of post-intensive care syndrome in the elderly remain uncertain.

OBJECTIVE

To investigate the association between socioeconomic status (SES) and risk of developing dementia within two years following critical care.

METHODS

This study included participants from the Korean National Health Insurance Service Cohort Database who had not been diagnosed with dementia and had been hospitalized in the ICU from 2003 to 2019. Dementia was determined using specific diagnostic codes (G30, G31) and prescription of certain medications (rivastigmine, galantamine, memantine, or donepezil). SES was categorized into low (medical aid beneficiaries) and non-low (National Health Insurance) groups. Through a 1:3 propensity score matching based on sex, age, Charlson comorbidity index, and primary diagnosis, the study included 16,780 patients. We used Cox proportional hazard models to estimate adjusted hazard ratios (HR) of dementia.

RESULTS

Patients with low SES were higher risk of developing dementia within 2 years after receiving critical care than those who were in non-low SES (HR: 1.23, 95% CI: 1.04-1.46). Specifically, patients with low SES and those in the high-income group exhibited the highest incidence rates of developing dementia within two years after receiving critical care, with rates of 3.61 (95% CI: 3.13-4.17) for low SES and 2.58 (95% CI: 2.20-3.03) for high income, respectively.

CONCLUSIONS

After discharge from critical care, compared to the non-low SES group, the low SES group was associated with an increased risk of developing dementia.

Social determinants of health and cognitive function: A cross-sectional study among men without dementia

BACKGROUND

Certain age-related and medical factors have been associated with cognitive dysfunction; however, less is known regarding social determinants of health. The current study aimed to investigate associations between social determinants of health and cognitive function in a population-based sample of men without dementia.

METHODS

Data were drawn from the ongoing Geelong Osteoporosis Study (n = 536). Cognitive function was determined using the Cog-State Brief Battery. Area-based socioeconomic status (SES) was determined using the Index of Relative Socioeconomic Advantage and Disadvantage, marital status by self-report, and social support by the Multidimensional Scale of Perceived Social Support, which considers family, friends, and significant others.

RESULTS

Belonging to a higher SES group, being in a relationship (married/de-facto) and perceived social support from a significant other and friends were each associated with better overall cognitive function. In regard to the specific cognitive domains, higher SES was associated with better psychomotor function and visual learning, being in a relationship was associated with better working memory, and perceived social support from a significant other was associated with better attention and working memory, with perceived social support from friends associated with better psychomotor function. There were no associations detected between social support from family and any of the cognitive domains.

CONCLUSION

Higher SES, being in a relationship, and greater perceived social support from a significant other and friends were associated with better cognitive function. Further studies identifying underlying mechanisms linking social factors with cognition are needed to establish prevention strategies and enhance cognitive health.

Cognitive reserve and individual differences in brain tumour patients

The aim of the paper is to determine the effects of the cognitive reserve on brain tumour patients' cognitive functions and, specifically, if cognitive reserve helps patients cope with the negative effects of brain tumours on their cognitive functions. We retrospectively studied a large sample of around 700 patients, diagnosed with a brain tumour. Each received an MRI brain examination and performed a battery of tests measuring their cognitive abilities before they underwent neurosurgery. To account for the complexity of cognitive reserve, we construct our cognitive reserve proxy by combining three predictors of patients' cognitive performance, namely, patients' education, occupation, and the environment where they live. Our statistical analysis controls for the type, side, site, and size of the lesion, for fluid intelligence quotient, and for age and gender, in order to tease out the effect of cognitive reserve on each of these tests. Clinical neurological variables have the expected effects on cognitive functions. We find a robust positive effect of cognitive reserve on patients' cognitive performance. Moreover, we find that cognitive reserve modulates the effects of the volume of the lesion: the additional negative impact of an increase in the tumour size on patients' performance is less severe for patients with higher cognitive reserve. We also find substantial differences in these effects depending on the cerebral hemisphere where the lesion occurred and on the cognitive function considered. For several of these functions, the positive effect of cognitive reserve is stronger for patients with lesions in the left hemisphere than for patients whose lesions are in the right hemisphere. The development of prevention strategies and personalized rehabilitation interventions will benefit from our contribution to understanding the role of cognitive reserve, in addition to that of neurological variables, as one of the factors determining the patients' individual differences in cognitive performance caused by brain tumours.

Frequency of missed or delayed diagnosis in dementia is associated with neighborhood socioeconomic status

Introduction

Underdetection of dementia in areas with low socioeconomic status (SES) may interfere with findings concerning associations between SES and dementia.

Methods

Using administrative registers we assessed the associations between age- and sex-adjusted dementia incidence and neighborhood socioeconomic status (nSES) in 94 Danish municipalities. Wealth was divided into income quartiles and other nSES variables were dichotomized into high versus low according to the median.

Results

High population density (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.18-1.24), higher proportion of inhabitants in higher income quartiles (P for trend < .0001), and high educational level (OR 1.19, 95% CI 1.15-1.22) were associated with higher incidence of dementia. High proportion of residents above 65 years was associated with lower age-adjusted dementia incidence (OR 0.86, 95% CI 0.84-0.89).

Discussion

Low nSES municipalities have a lower age-adjusted incidence of dementia diagnosis. These findings corroborate prior concerns that a large number of dementia diagnoses may be missed in municipalities characterized by low SES.

Societal and equity challenges for Brain Health Services. A user manual for Brain Health Services-part 6 of 6

Brain Health Services are a novel approach to the personalized prevention of dementia. In this paper, we consider how such services can best reflect their social, cultural, and economic context and, in doing so, deliver fair and equitable access to risk reduction. We present specific areas of challenge associated with the social context for dementia prevention. The first concentrates on how Brain Health Services engage with the "at-risk" individual, recognizing the range of factors that shape an individual's risk of dementia and the efficacy of risk reduction measures. The second emphasizes the social context of Brain Health Services themselves and their ability to provide equitable access to risk reduction. We then elaborate proposals for meeting or mitigating these challenges. We suggest that considering these challenges will enable Brain Health Services to address two fundamental questions: the balance between an individualized "high-risk" and population focus for public health prevention and the ability of services to meet ethical standards of justice and health equity.

Association of Socioeconomic Status With Dementia Diagnosis Among Older Adults in Denmark

IMPORTANCE

Low socioeconomic status (SES) has been identified as a risk factor for the development of dementia. However, few studies have focused on the association between SES and dementia diagnostic evaluation on a population level.

OBJECTIVE

To investigate whether household income (HHI) is associated with dementia diagnosis and cognitive severity at the time of diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This population- and register-based cross-sectional study analyzed health, social, and economic data obtained from various Danish national registers. The study population comprised individuals who received a first-time referral for a diagnostic evaluation for dementia to the secondary health care sector of Denmark between January 1, 2017, and December 17, 2018. Dementia-related health data were retrieved from the Danish Quality Database for Dementia. Data analysis was conducted from October 2019 to December 2020.

EXPOSURES

Annual HHI (used as a proxy for SES) for 2015 and 2016 was obtained from Statistics Denmark and categorized into upper, middle, and lower tertiles within 5-year interval age groups.

MAIN OUTCOMES AND MEASURES

Dementia diagnoses (Alzheimer disease, vascular dementia, mixed dementia, dementia with Lewy bodies, Parkinson disease dementia, or other) and cognitive stages at diagnosis (cognitively intact; mild cognitive impairment but not dementia; or mild, moderate, or severe dementia) were retrieved from the database. Univariable and multivariable logistic and linear regressions adjusted for age group, sex, region of residence, household type, period (2017 and 2018), medication type, and medical conditions were analyzed for a possible association between HHI and receipt of dementia diagnosis.

RESULTS

Among the 10 191 individuals (mean [SD] age, 75 [10] years; 5476 women [53.7%]) included in the study, 8844 (86.8%) were diagnosed with dementia. Individuals with HHI in the upper tertile compared with those with lower-tertile HHI were less likely to receive a dementia diagnosis after referral (odds ratio, 0.65; 95% CI, 0.55-0.78) and, if diagnosed with dementia, had less severe cognitive stage (β, -0.16; 95% CI, -0.21 to -0.10). Individuals with middle-tertile HHI did not significantly differ from those with lower-tertile HHI in terms of dementia diagnosis (odds ratio, 0.92; 95% CI, 0.77-1.09) and cognitive stage at diagnosis (β, 0.01; 95% CI, -0.04 to 0.06).

CONCLUSIONS AND RELEVANCE

The results of this study revealed a social inequality in dementia diagnostic evaluation: in Denmark, people with higher income seem to receive an earlier diagnosis. Public health strategies should target people with lower SES for earlier dementia detection and intervention.

The Factors Associated with 3-Year Mortality Stratified by Physical and Mental Multimorbidity and Area of Residence Deprivation in Primary Care Community-Living Older Adults

Objectives: To examine the risk factors of mortality stratified by physical and mental multimorbidity (PMM) and area socioeconomic status. Methods: Cox regression analyses were used to study 3-year all-cause mortality in primary care older adults stratified by PMM status, and area of residence material and social deprivation. Results: There were socioeconomic differences in the associations between PMM and mortality. Continuity of care decreased mortality risk in moderately and most deprived areas. Satisfaction with medical consultations decreased mortality risk in moderately deprived areas. Current smoking increased mortality in those living in moderately and most deprived areas. Physical activity reduced mortality only in individuals without PMM. Higher cognition was associated with reduced mortality in individuals living in moderately deprived areas. Discussion: Public health policies should be further encouraged in primary care, aiming at increased continuity of care, quality of interactions with patients, and prevention strategies including smoking cessation programs and physical activity promotion.

Parental Education, Household Income, Race, and Children's Working Memory: Complexity of the Effects

Background. Considerable research has linked social determinants of health (SDoHs) such as race, parental education, and household income to school performance, and these effects may be in part due to working memory. However, a growing literature shows that these effects may be complex: while the effects of parental education may be diminished for Blacks than Whites, household income may explain such effects. Purpose. Considering race as sociological rather than a biological construct (race as a proxy of racism) and built on Minorities' Diminished Returns (MDRs), this study explored complexities of the effects of SDoHs on children's working memory. Methods. We borrowed data from the Adolescent Brain Cognitive Development (ABCD) study. The total sample was 10,418, 9- and 10-year-old children. The independent variables were race, parental education, and household income. The primary outcome was working memory measured by the NIH Toolbox Card Sorting Test. Age, sex, ethnicity, and parental marital status were the covariates. To analyze the data, we used mixed-effect regression models. Results. High parental education and household income were associated with higher and Black race was associated with lower working memory. The association between high parental education but not household income was less pronounced for Black than White children. This differential effect of parental education on working memory was explained by household income. Conclusions. For American children, parental education generates unequal working memory, depending on race. This means parental education loses some of its expected effects for Black families. It also suggests that while White children with highly educated parents have the highest working memory, Black children report lower working memory, regardless of their parental education. This inequality is mainly because of differential income in highly educated White and Black families. This finding has significant public policy and economic implications and suggests we need to do far more than equalizing education to eliminate racial inequalities in children's cognitive outcomes. While there is a need for multilevel policies that reduce the effect of racism and social stratification for middle-class Black families, equalizing income may have more returns than equalizing education.

Lifestyle intervention to prevent Alzheimer's disease

Alzheimer's disease (AD) is the most common neurodegenerative disease that leads to significant morbidities in elderly. The major pathological hallmark of AD is beta-amyloid plaques (Aβ) and intracellular neurofibrillary tangles (NFTs) deposition in hippocampus of the brain. These abnormal protein deposition damages neuronal cells resulting in neurodegeneration and cognitive decline. As a result of limited treatment options available for this disease, there is huge economic burden for patients and social health care system. Thus, alternative approaches (lifestyle intervention) to prevent this disease are extremely important. In this systemic review, we summarized epidemiological evidence of lifestyle intervention and the mechanisms involved in delaying and/or preventing AD. Lifestyle interventions include education, social engagement and cognitive stimulation, smoking, exercise, depression and psychological stress, cerebrovascular disease (CVD), hypertension (HTN), dyslipidaemia, diabetes mellitus (DM), obesity and diet. The methods are based on a literature review of available sources found on the research topic in four acknowledged databases: Web of Science, Scopus, Medline and PubMed. Results of the identified original studies revealed that lifestyle interventions have significant effects and our conclusion is that combination of early lifestyle interventions can decrease the risk of developing AD.

Ethnic disparity in access to the memory assessment service between South Asian and white British older adults in the United Kingdom: A cohort study

BACKGROUND

Equality of access to memory assessment services by older adults from ethnic minorities is both an ethical imperative and a public health priority.

OBJECTIVE

To investigate whether timeliness of access to memory assessment service differs between older people of white British and South Asian ethnicity.

DESIGN

Longitudinal cohort.

SETTING

Nottingham Memory Study; outpatient secondary mental healthcare.

SUBJECTS

Our cohort comprised 3654 white British and 32 South Asian older outpatients.

METHODS

The criterion for timely access to memory assessment service was set at 90 days from referral. Relationships between ethnicity and likelihood of timely access to memory assessment service were analysed using binary logistic regression. Analyses were adjusted for socio-demographic factors, deprivation and previous access to rapid response mental health services.

RESULTS

Among white British outpatients, 2272 people (62.2%) achieved timely access to memory assessment service. Among South Asian outpatients, fourteen people (43.8%) achieved timely access to memory assessment service. After full adjustment, South Asian outpatients had a 0.47-fold reduced likelihood of timely access, compared to white British outpatients (odds ratio 0.47, 95% confidence interval 0.23-0.95, P value = .035). The difference became non-significant when restricting analyses to outpatients reporting British nationality or English as first language. Older age, lower index of deprivation and previous access to rapid response mental health services were associated with reduced likelihood of timely access, while gender was not.

CONCLUSIONS

In a UK mental healthcare service, older South Asian outpatients are less likely to access dementia diagnostic services in a timely way, compared to white British outpatients.

Family history of Alzheimer's disease alters cognition and is modified by medical and genetic factors

In humans, a first-degree family history of dementia (FH) is a well-documented risk factor for Alzheimer’s disease (AD); however, the influence of FH on cognition across the lifespan is poorly understood. To address this issue, we developed an internet-based paired-associates learning (PAL) task and tested 59,571 participants between the ages of 18–85. FH was associated with lower PAL performance in both sexes under 65 years old. Modifiers of this effect of FH on PAL performance included age, sex, education, and diabetes. The Apolipoprotein E ε4 allele was also associated with lower PAL scores in FH positive individuals. Here we show, FH is associated with reduced PAL performance four decades before the typical onset of AD; additionally, several heritable and non-heritable modifiers of this effect were identified.

Socioeconomic disparities in clinical trials on Alzheimer's disease: a systematic review

BACKGROUND AND PURPOSE

There is now a wide consensus at recognizing social and economic circumstances as main determinants of an individual's health status. Nevertheless, characteristics relating to socioeconomic status (SES) are poorly described in research reports. The aim of the present review was to verify whether the SES of participants is adequately reported in interventional studies targeting Alzheimer's disease (AD), and to explore the impact of SES proxy measures on the efficacy of the considered medications.

METHODS

A systematic review of available randomized controlled trials (RCTs) on the currently marketed drugs for AD (i.e. cholinesterase inhibitors and memantine) was conducted by performing a structured search on PubMed and the Cochrane databases. The following indicators of SES were considered in the retained studies: (i) educational level, (ii) lifetime job category, (iii) income and (iv) wealth. The study quality was assessed using the Cochrane Risk of Bias Tool for Randomized Controlled Trials.

RESULTS

A total of 48 articles were finally selected. Overall, only eight RCTs reported data concerning the four considered SES indicators. Indeed, only information pertaining to the educational level of participants was provided. Only one RCT (n = 60) performed ad hoc, secondary analyses accounting for the SES of participating subjects.

CONCLUSIONS

The research and clinical relevance of SES has mistakenly been overlooked by the vast majority of RCTs on AD. A greater effort should be made to collect and report data on those SES indicators that may significantly affect the clinical manifestations and trajectories of patients with cognitive disturbances.

Socio-economic status influences access to second-line disease modifying treatment in Relapsing Remitting Multiple Sclerosis patients

Objective

In MS, Socio-Economic status (SES) may influence healthcare and access to disease-modifying treatments (DMTs). Optimising delays to switch patients to a second-line DMT may hamper disease progression most effectively and achieve long term disease control. The objective of this study is to identify the influence of SES on the delay between first and second line DMT in RRMS patients, in Western-Normandy, France.

Methods

The association between SES and the delay to access a second-line DMT were studied using data from the MS registry of Western-Normandy including 733 patients with a diagnosis of RRMS during the period in question [1982–2011]. We used the European Deprivation Index (EDI), a score with a rank level inversely related to SES. We performed multivariate adjusted Cox models for studying EDI effect on the delay between first and second line DMT.

Results

No significant influence of SES was observed on delay to access a second-line DMT if first-line DMT exposure time was less than 5 years. After 5 years from initiation of first-line treatment the risk of accessing a second-line DMT is 3 times higher for patients with lower deprivation indices (1^st quintile of EDI) ([HR] 3.14 95%CI [1.72–5.72], p-value<0.001) compared to patients with higher values (EDI quintiles 2 to 5).

Interpretation

In RRMS, a high SES may facilitate access to a second-line DMT a few years after first-line DMT exposure. Greater consideration should also be given to the SES of MS patients as a risk factor in therapeutic healthcare issues throughout medical follow-up.

Time to diagnosis in young-onset dementia and its determinants: the INSPIRED study

OBJECTIVE

The objective of this study is to identify factors determining the time to diagnosis for young-onset dementia (YOD), defined as dementia with symptom onset before age 65 years, by mapping the diagnostic pathways.

METHODS

Participants were recruited via healthcare professionals, community support organisations or were self-referred. Information was obtained by interviews with the person with YOD and their carer, and medical record reviews. Clinical dementia diagnoses were independently ratified by consensus review.

RESULTS

Participants included 88 people with YOD (mean age of onset = 55.4 years), due to Alzheimer's disease (AD) (53.4%, n = 47), frontotemporal dementia (FTD) (15.9%, n = 14) and other causes (30.7%, n = 27). Median time from symptom onset to first consultation was 2.3 years, to dementia diagnosis 3.2 years, to family awareness of dementia diagnosis 3.5 years and to final diagnosis of the type of dementia 4.7 years. Non-dementia diagnoses occurred in 48.9%, including depression (30.7%) and mild cognitive impairment (MCI) (17.0%). Participants with younger age of onset had significantly longer time to first consultation and family awareness of the dementia diagnosis. The time to dementia diagnosis was significantly longer when the participant presented with MCI or depression and when the dementia was other than AD or FTD. MCI was associated with significantly longer time to family awareness of dementia diagnosis.

CONCLUSIONS

Factors impacting on time to diagnosis vary with the stage of diagnosis in YOD. Longer time to dementia diagnosis occurred in people who were younger at symptom onset, when MCI or depression was present, and in dementias other than AD and FTD. Copyright © 2016 John Wiley & Sons, Ltd.

Which Stratum of Urban Elderly Is Most Vulnerable for Dementia?

Many factors associated with a patient's lifestyle may disrupt timely access to dementia diagnosis and management. The aim of this study was to compare characteristics of lifestyle factors at the time of initial evaluation for dementia across degrees of dementia, and to identify risk factors relating to late detection of dementia, in order to understand the various lifestyle barriers to timely recognition of the disease. We reviewed medical records of 1,409 subjects who were diagnosed as dementia among 35,723 inhabitants of Gwangjin-gu. Dementia severity was divided into three degrees. Age, sex, education, income, smoking, heavy drinking, physical activity, religion, and living conditions were evaluated. There was a significantly greater proportion of individuals who were old age, female, less educated, who had never smoked or drank heavily, without physical activity, with no religious activity and living with family other than spouse in the severe dementia group. The lifestyle risks of late detection were old age, lower education, less social interactions, less physical activity or living with family. We can define this group of patients as the vulnerable stratum to dementia evaluation. Health policy or community health services might find ways to better engage patients in this vulnerable stratum to dementia.

Socioeconomic Disparities and Mortality After a Diagnosis of Dementia: Results From a Nationwide Registry Linkage Study

Low socioeconomic status (SES) has been linked to a higher incidence of dementia. Less is known about the association between SES and mortality in persons with dementia. We studied this association in a prospective cohort of 15,558 patients in the Netherlands between 2000 and 2010. SES was measured using disposable household income and divided in tertiles. Overall, there was a negative relationship between SES and mortality in both sexes and both settings of care. For men who visited a day clinic, the 5-year mortality rate was 74% among those in the lowest tertile of SES and 57% among those in the highest; for women, the rates were 60% and 50%, respectively. The differences in median survival times between persons in the lower and upper tertiles of SES were 260 days for men and 300 days for women. For men who were admitted to the hospital, the 5-year mortality rate was 89% among those in the lowest tertile of SES and 86% among those in the highest; for women, the rates were 83% and 77%, respectively. The differences in median survival times between persons in the lower and upper tertiles of SES were 80 days for men and 130 days for women. Among patients who visited a day clinic, for patients in the lowest tertile of SES versus those in the highest, the adjusted hazard ratio was 1.41 (95% confidence interval: 1.26, 1.57); for those admitted to the hospital, it was 1.14 (95% confidence interval: 1.07, 1.20). In summary, lower SES was associated with a higher mortality risk in both men and women with dementia. The results of the present study should raise awareness in clinicians and caregivers about the unfavorable prognosis in the most deprived patients.

Observational cohort study: deprivation and access to anti-dementia drugs in the UK

BACKGROUND

UK National Dementia Strategies prioritise fair access to dementia treatments for the whole population. We investigated for the first time inequalities in NHS national dementia prescribing and how they have varied between UK countries and over time.

METHOD

we investigated the association between Townsend deprivation score and anti-dementia drug prescribing in 77,045 dementia patients from UK primary care records from 2002 to 2013.

RESULTS

we included 77,045 patients with recorded dementia diagnosis or anti-dementia drug prescription. Least deprived patients were 25% more likely to be initiated on anti-dementia drugs than the most deprived (adjusted incidence rate ratio 1.25, 95% confidence interval 1.19-1.31). This was driven by data from English practices where prescribing rates were consistently lower in more deprived patients compared with Scotland, Northern Ireland and Wales, where prescribing was not related to deprivation quintile. Compared with English practices, anti-dementia medication was prescribed more often in Northern Irish (1.81, 1.41-2.34) and less in Welsh practices (0.68, 0.55-0.82), with a trend towards more prescribing in Scottish practices (1.14, 0.98-1.32). Drug initiation rates were also higher in younger people and men.

CONCLUSION

four years after the English National Dementia Strategy, there is no evidence that the Strategy's key objective of reducing treatment inequalities is being achieved. Higher overall anti-dementia drug prescribing in Scottish and Northern Irish practices, and differing clinical guidelines in Scotland from other UK countries might explain greater equality in prescribing in these countries. Strategies to offer treatment to more deprived people with dementia in England are needed.

The Role of Employment on Neurocognitive Reserve in Adults With HIV: A Review of the Literature

The benefits of employment are enormous; when employed, people naturally: (a) engage socially with the public and colleagues/co-workers, (b) learn new skills to increase job productivity and competence, (c) establish routines that can prevent lethargy and boredom and may regulate sleep and healthy behaviors, (d) are provided purposeful and meaningful activity that may prevent depression, and (e) gain income to pursue cognitively stimulating interests. All of these and other employment influences can provide an enriched personal and social environment that stimulates positive neuroplasticity and promotes neurocognitive reserve, which are particularly relevant to adults with HIV because (a) approximately 50% of adults with HIV experience observable cognitive impairments that can adversely affect everyday functioning such as medication adherence, and (b) approximately 45% of adults with HIV are unemployed and do not receive the neurocognitive benefits of employment. From these considerations, implications for health care research and nursing practice are provided.

Drug utilization pattern in patients with different types of dementia in Western India

Background. Dementia is one of the most frequent disorders among elderly patients, reaching to epidemic proportions with an estimated 4.6 million new cases globally annually. Partially effective treatments are available for dementia. Aims & Objectives. We aim to study drugs used in dementia and find out frequency of types of Dementia. Method. This was an observational study conducted at rurally based tertiary care hospital. Prospective data was collected from outpatient department, while retrospective data was collected from medical records. Descriptive statistics were used to analyze data. Result. Total 125 prescriptions of patients diagnosed with dementia were analyzed. Alzheimer's dementia was most common (65.6%), followed by vascular dementia (21.6%), and frontotemporal dementia (10.4%), with the rarest being Lewy body dementia in (2.4%) cases. 60.57% of patients were males. Mini Mental Score Examination mean score was 15.93 ± 1.37. Frontal Battery Assessment mean score was 4.75 ± 1.01. Prescribed drugs were Donepezil (68.49%), Rivastigmine (13.63%), Donepezil + Memantine (6.43%) and Galantamine (12.83%), Quetiapine (38.46%), Lorazepam (23.07%), Clozapine (11.53%), Escitalopram (10.25%), Haloperidol (3.84%), Zolpidem, Sertraline, Olanzepine (2.56%), Nitrazepine, Lamotrigine, Fluoxetine, Tianeptine (1.28%), Folic acid, and Vitamin B12, respectively. Conclusion. Alzheimer's is the most common type of dementia while Donepezil was the most frequent drug.