Clinical evaluation of brief cognitive assessment measures for patients with severe dementia

Electroconvulsive therapy for the acute management of severe agitation in dementia (ECT-AD): A modified study protocol

OBJECTIVE

This study began as a single-blind randomized controlled trial (RCT) to investigate the efficacy and safety of electroconvulsive therapy (ECT) for severe treatment-refractory agitation in advanced dementia. The aims are to assess agitation reduction using the Cohen-Mansfield Agitation Inventory (CMAI), evaluate tolerability and safety outcomes, and explore the long-term stability of agitation reduction and global functioning. Due to challenges encountered during implementation, including recruitment obstacles and operational difficulties, the study design was modified to an open-label format and other protocol amendments were implemented.

METHODS

Initially, the RCT randomized participants 1:1 to either ECT plus usual care or simulated ECT plus usual care (S-ECT) groups. As patients were enrolled, data were collected from both ECT and simulated ECT (S-ECT) patients. The study now continues in an open-label study design where all patients receive actual ECT, reducing the targeted sample size from 200 to 50 participants.

RESULTS

Study is ongoing and open to enrollment.

CONCLUSION

The transition of the ECT-AD study design from an RCT to open-label design exemplifies adaptive research methodologies in response to real-world challenges. Data from both the RCT and open-label phases of the study will provide a unique perspective on the role of ECT in managing severe treatment-refractory agitation in dementia, potentially influencing future clinical practices and research approaches.

A Novel Approach to Monitoring Cognitive Adverse Events for Interventional Studies Involving Advanced Dementia Patients: Insights From the Electroconvulsive Therapy for Agitation in Dementia Study

OBJECTIVE

To develop an individualized method for detecting cognitive adverse events (CAEs) in the context of an ongoing trial of electroconvulsive therapy for refractory agitation and aggression for advanced dementia (ECT-AD study).

METHODS

Literature search aimed at identifying (a) cognitive measures appropriate for patients with advanced dementia, (b) functional scales to use as a proxy for cognitive status in patients with floor effects on baseline cognitive testing, and (c) statistical approaches for defining a CAE, to develop CAEs monitoring plan specifically for the ECT-AD study.

RESULTS

Using the Severe Impairment Battery-8 (SIB-8), baseline floor effects are defined as a score of ≤5/16. For patients without floor effects, a decline of ≥6 points is considered a CAE. For patients with floor effects, a decline of ≥30 points from baseline on the Barthel Index is considered a CAE. These values were derived using the standard deviation index (SDI) approach to measuring reliable change.

CONCLUSIONS

The proposed plan accounts for practical and statistical challenges in detecting CAEs in patients with advanced dementia. While this protocol was developed in the context of the ECT-AD study, the general approach can potentially be applied to other interventional neuropsychiatric studies that carry the risk of CAEs in patients with advanced dementia.

Long-Term, All-Day Exposure to Circadian-Effective Light Improves Sleep, Mood, and Behavior in Persons with Dementia

Background

Persons with Alzheimer's disease and related dementias (ADRD) frequently experience sleep-wake (circadian) cycle disturbances that lead them to remain awake at night, causing stress and fatigue for families and caregivers. Light therapy shows promise as a nonpharmacological treatment for regulating sleep in this population.

Objective

We investigated the long-term impact of a circadian-effective lighting intervention on sleep, mood, and behavior problems in persons with ADRD.

Methods

This 25-week clinical trial administered an all-day lighting intervention to 47 patients with ADRD in 9 senior-care facilities, employing wrist-worn actigraphy measures and standardized measures of sleep quality, mood, and behavior.

Results

The intervention significantly improved Pittsburgh Sleep Quality Index scores, from an estimated mean±SEM of 11.89±0.53 at baseline to 5.36±0.63 at the end of the intervention. Additional improvements were noted for sleep efficiency data from actigraph measurements. The intervention significantly reduced Cornell Scale for Depression in Dementia scores (mean±SEM of 11.36±0.74 at baseline and 4.18±0.88 at the end of the intervention) and Cohen-Mansfield Agitation Inventory scores (mean±SEM of 47.10±1.98 at baseline and 35.33±2.23 at the end of the intervention).

Conclusion

A regular circadian-effective daytime lighting intervention can improve sleep at night and reduce depression and agitation in patients with dementia living in controlled environments. More importantly, the positive effects of the tailored lighting intervention on these outcomes appear to be cumulative over time.

Eye tracking metrics to screen and assess cognitive impairment in patients with neurological disorders

PURPOSE OF REVIEW

Eye tracking is a powerful method to investigate the relationship between behavior and neural mechanisms. In recent years, eye movement analysis has been used in patients with neurological disorders to assess cognitive function. In this review, we explore the latest eye tracking researches in neurological disorders that are commonly associated with cognitive deficits, specifically, amyotrophic lateral sclerosis (ALS), Alzheimer's disease (AD), Parkinson's disease (PD), multiple sclerosis (MS), and epilepsy. We focus on the application of ocular measures in these disorders, with the goal of understanding how eye tracking technology can be used in the clinical setting.

FINDINGS

Eye tracking tasks (especially saccadic tasks) are often used as an adjunct to traditional scales for cognitive assessment. Eye tracking data confirmed that executive dysfunction is common in PD and ALS, whereas AD and MS are characterized by attention deficits. Research in evaluating cognitive function in epilepsy using eye tracking is still in its early stages, but this approach has shown advantages as a sensitive quantitative method with high temporal and spatial resolution. Eye tracking technology can facilitate the assessment of cognitive impairment with higher temporal resolution and finer granularity than traditional cognitive assessment. Oculomotor data collected during cognitive tasks can provide insight into biological processes. Eye tracking provides a nonverbal and less cognitively demanding method of measuring disease progression in cognitively impaired patients.

The Turkish Version of Pain Assessment in Advanced Dementia (PAINAD) Scale

Introduction

This study was conducted to test the reliability and validity of the Turkish version of the "Pain Assessment In Advanced Dementia (PAINAD) Scale".

Methods

One hundred and six older adults with advanced dementia (AD) were recruited in the study. Detailed medical history and demographic data of the participants were recorded. Initially, the Turkish version of PAINAD (PAINAD-TR), which was prepared by means of "back-translation", was applied. Along with this scale, Mini Mental State Examination, Clinical Dementia Rating scale, and Visual Analog Scale were also used.

Results

The Cronbach's α coefficient was 0.82 and 0.85 for the test and re-test, respectively. For the test-retest reliability of the PAINAD-TR scale, values of the intraclass correlation coefficient (ICC) and 95% confidence interval (CI) were 0.812 and 0.763-0.850 respectively. According to the results of a factor analysis carried out on the scale, a 2-domain structure was proved.

Conclusion

The PAINAD-TR scale can be used for the assessment and management of pain in non-communicative older adults with AD.

Visual Restoration after Cataract Surgery Promotes Functional and Structural Brain Recovery

Background

Visual function and brain function decline concurrently with aging. Notably, cataract patients often present with accelerated age-related decreases in brain function, but the underlying mechanisms are still unclear. Optical structures of the anterior segment of the eyes, such as the lens and cornea, can be readily reconstructed to improve refraction and vision quality. However, the effects of visual restoration on human brain function and structure remain largely unexplored.

Methods

A prospective, controlled clinical trial was conducted. Twenty-six patients with bilateral age-related cataracts (ARCs) who underwent phacoemulsification and intraocular lens implantation and 26 healthy controls without ARC, matched for age, sex, and education, were recruited. Visual functions (including visual acuity, visual evoke potential, and contrast sensitivity), the Mini-Mental State Examination and functional magnetic resonance imaging (including the fractional amplitude of low-frequency fluctuations and grey matter volume variation) were assessed for all the participants and reexamined for ARC patients after cataract surgery. This trial was registered with ClinicalTrials.gov (NCT02644720).

Findings

Compared with the healthy controls, the ARC patients presented decreased brain functionality as well as structural alterations in visual and cognitive-related brain areas preoperatively. Three months postoperatively, significant functional improvements were observed in the visual and cognitive-related brain areas of the patients. Six months postoperatively, the patients' grey matter volumes in these areas were significantly increased. Notably, both the function and structure in the visual and cognitive-related brain areas of the patients improved significantly and became comparable to those of the healthy controls 6 months postoperatively.

Interpretation

We demonstrated that ocular reconstruction can functionally and structurally reverse cataract-induced brain changes. The integrity of the eye is essential for maintaining the structure and function of the brain within and beyond the primary visual pathway.

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Cataract patients with reduced visual function presented a simultaneous decrease in brain function and grey matter volume.

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Cataract surgery can reverse cerebral changes in both visual and cognitive-related regions associated with visual decline.

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The integrity of the eye is essential for maintaining the structure and function of the brain.

The eyes and brain are anatomically and functionally connected. Age related cataract (ARC) is associated with structural and functional impairments of the brain. However, whether these changes are reversible after cataract surgery is largely unknown. We assessed the patients based on subjective cognitive evaluations and objective functional magnetic resonance imaging before and after surgery. Significant improvements in brain function and increases in the grey matter volumes of the visual, cognitive-related, and somatosensory brain areas were observed, demonstrating that the impaired brain function and structure of ARC patients can be reversed after restoration of visual acuity.