The prevalence of dementia in older people in an urban population of Korea: the Seoul study

CERAD (Consortium to Establish a Registry for Alzheimer's Disease) Neuropsychology Assessment Battery: 35 Years and Counting

BACKGROUND

In 1986, the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) was mandated to develop a brief neuropsychological assessment battery (CERAD-NAB) for AD, for uniform neuropsychological assessment, and information aggregation. Initially used across the National Institutes of Aging-funded Alzheimer's Disease Research Centers, it has become widely adopted wherever information is desired on cognitive status and change therein, particularly in older populations.

OBJECTIVE

Our purpose is to provide information on the multiple uses of the CERAD-NAB since its inception, and possible further developments.

METHODS

Since searching on "CERAD neuropsychological assessment battery" or similar terms missed important information, "CERAD" alone was entered into PubMed and SCOPUS, and CERAD-NAB use identified from the resulting studies. Use was sorted into major categories, e.g., psychometric information, norms, dementia/differential dementia diagnosis, epidemiology, intervention evaluation, genetics, etc., also translations, country of use, and alternative data gathering approaches.

RESULTS

CERAD-NAB is available in ∼20 languages. In addition to its initial purpose assessing AD severity, CERAD-NAB can identify mild cognitive impairment, facilitate differential dementia diagnosis, determine cognitive effects of naturally occurring and experimental interventions (e.g., air pollution, selenium in soil, exercise), has helped to clarify cognition/brain physiology-neuroanatomy, and assess cognitive status in dementia-risk conditions. Surveys of primary and tertiary care patients, and of population-based samples in multiple countries have provided information on prevalent and incident dementia, and cross-sectional and longitudinal norms for ages 35-100 years.

CONCLUSION

CERAD-NAB has fulfilled its original mandate, while its uses have expanded, keeping up with advances in the area of dementia.

Cognitive decline sensitivity by educational level and residential area: A descriptive study using long-term care insurance dementia registration data in South Korea

In South Korea Long-Term Care Insurance (LTCI) system, the special dementia rating (SDR) is a registration grading for dementia patients who do not have a physical disability or functional restrictions and is the first applicable registration following the diagnosis of dementia. We investigated the differences in age of registration of SDR and age of dementia diagnosis according to the educational level and residential area. This was a retrospective, cross-sectional study using the Korean National Health Insurance Service dataset. Applications for SDR between July 2014 and December 2016 were identified for participant selection, and 32,352 patients with dementia were included. Educational levels were defined as follows: the illiterate, only-reading, 1 to 6 years, 6 to 12 years, and ≥12 years. Urban residents were those who lived in the city, as ascertained from the Korean administrative district system. The primary outcomes were ages at the time of dementia diagnosis and SDR registration. A lower education level significantly correlated with a higher proportion of older adults, but a higher number of years of education significantly increased with the proportion of males and urban residents (P < .001 for all). A higher education level was inversely associated with the age at diagnosis of dementia (P < .001) and at the registration of SDR (P < .001). Urban residents were diagnosed with dementia at a significantly lower age and registered for SDR earlier than rural residents (P < .001 for both). Both urban and rural residents consistently showed that a higher educational level was associated with lower age at the dementia diagnosis and SDR registration. Patients who were highly educated and living in urban areas were diagnosed with dementia and registered on SDR when they were relatively younger, indicating that cognitive decline sensitivity and medical accessibility are related to earlier dementia diagnosis and registration.

Validation of the Greek version of the Abbreviated Mental Test Score: Preliminary findings for cognitively impaired patients of different etiology

BACKGROUND

Screening people's cognitive skills have been proven essential for reference to full assessment. These methods include short scales, such as the Abbreviated Mental Test Score (AMTS). The AMTS is a valid 10-item questionnaire that has been translated into many languages, but not in Greek yet. The aim of this study is the validation of the Greek version of the AMTS with an additional estimation of its cutoff scores.

METHODS

About 132 individuals [60 controls and 72 patients (24 with Parkinson's disease (PD), 24 with Parkinson's disease dementia (PDD), and 24 with Alzheimer's disease (AD)] participated in this study. All participants besides the AMTS completed the Mini Mental State Examination (MMSE), the Tuokko's Clock Drawing Test (CDT), the Instrumental Activities of Daily Living (IADL), the Arizona Battery for Communication Disorders of Dementia (ABCD), the Hellenic versions of the Neuropsychiatric Inventory (NPI), and the Geriatric Depression Scale (GDS-15).

RESULTS

Statistically significant differences were found between all subgroups for the AMTS. The AMTS showed high internal consistency (Cronbach alpha = 0.819 and coefficient omega ω = 0.814). A threshold equal to 6.50 (AUC: 0.908, p = 0.000) between groups with and without cognitive impairment was calculated. The AMTS was significantly correlated with the CDT, IADL, and MMSE.

CONCLUSION

The proposed version of the AMTS can distinguish between groups with and without cognitive impairment. Additionally, the AMTS is found to be clinically valid having high reliability and classification accuracy. Conclusively, it is a valuable instrument for screening different types of cognitively impaired patients.

Efficacy of geriatric multidisciplinary oncology clinic in the surgical treatment decision-making process for frail elderly patients with colorectal cancer

Purpose

Multidisciplinary care has become a cornerstone of colorectal cancer management. To evaluate the clinical efficacy of a geriatric multidisciplinary oncology clinic (GMOC), we analyzed the surgical treatment decision-making process and outcomes.

Methods

This retrospective single-center study reviewed the data of patients aged ≥65 years who participated in the GMOC at a tertiary referral hospital between 2015 and 2021. The clinical adherence rate, comprehensive geriatric assessment, and a multidimensional frailty score (MFS) were obtained. The groups that were recommended and not recommended for surgery were compared, analyzing the factors impacting the decision and 1-year survival outcomes. Furthermore, the postoperative complications of patients who underwent surgery were evaluated.

Results

A total of 165 patients visited the GMOC, and 74 had colorectal cancer (mean age, 85.5 years [range, 81.2–89.0 years]). Among patients with systemic disease (n = 31), 7 were recommended for surgery, and 5 underwent surgery. Among patients with locoregional disease (n = 43), 18 were recommended for surgery, and 12 underwent surgery. Patients recommended and not recommended for surgery had significantly different activities of daily living (ADL) (P = 0.024), instrumental ADL (P = 0.001), Mini-Mental State Examination (P = 0.014), delirium risk (P = 0.039), and MFS (P = 0.001). There was no difference in the 1-year overall survival between the 2 groups (P = 0.980). Of the 17 patients who underwent surgery, the median (interquartile range) of operation time was 165.0 minutes (120.0–270.0 minutes); hospital stay, 7.0 days (6.0–8.0 days); and 3 patients had wound complications.

Conclusion

Proper counseling of patients through the GMOC could lead to appropriate management and favorable outcomes.

How glutamatergic synapse loss affects the firing rhythm of DG-CA3 model related with Alzheimer's disease

As well known that synapse loss is a significant pathological feature of Alzheimer's disease (AD), meanwhile, the hippocampus is one of brain regions to be first affected in the early stage of AD. Thus, this work employs a comprehensive DG-CA3 network model of the hippocampus so as to explore the neuronal correlation between glutamatergic synapse loss and abnormal firing rhythm associated with AD from the perspective of neurocomputation. The neuropathological condition of glutamatergic synapse loss caused by the reduction of Shank3 protein in AD patients is imitated by decreasing glutamatergic excitatory synapse strength between different neurons. By means of power spectral analysis and dynamics technique, the numerical results reveal that excitability of pyramidal neuron as well as oriens lacunosum-moleculare (O-LM) cell in CA3 region is strongly degraded by the decrease of NMDA or AMPA-type glutamatergic excitatory synapse strength. Moreover, the relative power together with the peak of relative power density within alpha band is also diminished by decreasing glutamatergic synapse strength. These findings accord with the electrophysiological experiment of EEG that there is a decrease of alpha rhythm for AD patients, on the same time, they could highlight the significance of glutamatergic synapse loss in the pathogenesis of AD.

Prevalence of Dementia in Korea Based on Hospital Utilization Data from 2008 to 2016

PURPOSE

Dementia is an important health issue in Korea due to its associated medical costs. Our study aimed to estimate the prevalence of dementia in Korea by analyzing hospital utilization rates.

MATERIALS AND METHODS

We examined National Health Insurance data from 2008 to 2016 and identified all dementia cases. Crude and ageand sex-standardized prevalence were calculated. A generalized linear mixed model was used to estimate prevalence ratios.

RESULTS

We identified 176746 and 530269 dementia cases in 2008 and 2016, respectively. Alzheimer's disease was the most common dementia subtype (65.4% and 86.1% in 2008 and 2016, respectively). Across all age groups, the prevalence of dementia increased consistently: the increase was prominent among patients ≥85 years of age. Among patients ≥65 years of age, crude prevalence was estimated at 31.3 and 72.2 per 1000 population in 2008 and 2016, respectively. Age- and sex-standardized prevalence increased from 31.3 to 62.0 per 1000 population between 2008 and 2016, respectively. The prevalence ratio for dementia in 2016 was 2.02 times (95% confidence interval, 2.01-2.03) higher than that in 2008. When adjusted for age, dementia was more prevalent among females. The most common comorbidity was hypertension, followed by diabetes and stroke.

CONCLUSION

Our results demonstrated that hospital utilization for dementia increased significantly from 2008 to 2016, reflecting a proportional increase in the prevalence of dementia. Korean healthcare policy must prioritize dementia treatment.

A single-arm feasibility study of gradual dose de-escalation of antiemetic dexamethasone for older patients receiving chemotherapy

OBJECTIVES

To investigate whether discontinuation of prophylactic dexamethasone by gradual dose de-escalation is practicable in older patients with cancer undergoing moderately emetogenic chemotherapy.

MATERIALS AND METHODS

This single-arm, feasibility study prospectively enrolled 40 patients (≥70 years old) with colorectal cancer, who were scheduled to undergo adjuvant FOLFOX chemotherapy, and ten patients ≤60 years old to serve as a control group for pharmacokinetic study. All patients received an antiemetic regimen consisting of intravenous dexamethasone 8 mg and palonosetron at day 1 of the first cycle and underwent phone interviews using symptom questionnaires at day 7 of each cycle. Dexamethasone was tapered off through gradual de-escalation by 2 mg per cycle, when complete response (CR; no emesis and no rescue therapy) was achieved. Primary endpoint was the proportion of patients who discontinued dexamethasone completely.

RESULTS

The median age of the patient was 74 years, and 50% were male. Of the 40 patients, 36 completed twelve cycles of chemotherapy, and 73% (N = 29) were able to discontinue dexamethasone completely. The mean (±SD) dose of dexamethasone per cycle was 3.0 mg (±2.4 mg), which was reduced to 37.5% of the initial dose level. The severity of patient-reported nausea did not significantly change over chemotherapy cycle. Geriatric assessment revealed no decline in any domain and fasting blood glucose and hemoglobin A1c levels were not elevated after twelve cycles of chemotherapy, compared to the baseline.

CONCLUSION

Gradual dose de-escalation and discontinuation of prophylactic dexamethasone is feasible without compromising its antiemetic effect in older patients undergoing chemotherapy.

Prevalence and Incidence of Dementia in South Korea: A Nationwide Analysis of the National Health Insurance Service Senior Cohort

BACKGROUND AND PURPOSE

Dementia is rapidly becoming more common in the elderly population of South Korea, and there are regional difference in its demographics. This study investigated the trajectories in the prevalence and incidence of dementia based on the Seoul metropolitan area and other areas in South Korea using big data from the National Health Insurance Service (NHIS).

METHODS

We examined a population-based elderly cohort obtained from the NHIS Senior Cohort (NHIS-SC) data set that comprises approximately half a million recipients of medical insurance in South Korea during 2003-2015. The age-standardized prevalence and incidence of dementia as well as their trajectories from 2003 were estimated. Regional differences in these rates between Seoul metropolitan area and other areas were also analyzed.

RESULTS

The standardized prevalence of dementia per 100,000 increased significantly from 178.11 in 2003 to 5,319.01 in 2015 (p<0.001). The standardized prevalence of dementia was higher in other areas than in Seoul metropolitan area. The standardized incidence of dementia per 100,000 person-years also increased significantly, from 126.41 in 2003 to 2,218.25 in 2015 (p<0.001). The standardized incidence of dementia was similarly higher in other areas than in Seoul metropolitan area (p<0.001).

CONCLUSIONS

This study has shown that the standardized prevalence and incidence of dementia increased steadily from 2003 to 2015 in South Korea based on the NHIS-SC data set, and differed between Seoul metropolitan area and other areas.

Frontotemporal Dementia: A Cross-Cultural Perspective

It is predictable that syndromes of frontotemporal dementia (FTD) may have a worldwide distribution; however, data available on their incidence and prevalence are variable. This variability most likely reflects disparities across regions in the distribution of the expertise, technology, and resources available for FTD research and care. Important discoveries have been made regarding FTD's phenotypes, genetics, and cultural influences on the expression of symptoms; however, in many countries, there are barriers posed by a dearth of resources. There are pressing needs to further develop research on FTD: including first, population studies designed to fill the gaps in our knowledge about FTD's frequency and risk factors in developing regions and among minority groups in developed countries. It is also necessary to facilitate the psychometric characterization of contemporary diagnostic criteria and their translation to different languages and cultural contexts. Furthermore, much needed is the analysis of differences in the genetic risk factors for FTD, particularly non-Mendelian susceptibility factors. It is hoped that reflections on FTD from an international perspective will spur an extension of the vibrant multicenter collaborations, that exist in North America and Europe, toward new centers to be established and supported in the developing regions of the world.

Predictive Value of Comprehensive Geriatric Assessment on Early Postoperative Complications Following Lumbar Spinal Stenosis Surgery: A Prospective Cohort Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim of this study was to evaluate the predictive value of comprehensive geriatric assessment (CGA) for early postoperative complications in elderly patients (aged 65 years or older) following lumbar spinal stenosis surgery.

SUMMARY OF BACKGROUND DATA

CGA is a multidisciplinary evaluation modality proven to be effective in various fields of geriatrics. However, limited evidence exists on the effectiveness of CGA in lumbar spinal stenosis patients in the literature.

METHODS

We prospectively enrolled consecutive patients who were at least 65 years' old and were scheduled to undergo elective surgery for lumbar spinal stenosis. One day before the operation, multidomain CGA was performed on the patient's functional status, comorbidities, nutrition, cognition, and psychological status. Patients with deficits in three or more CGA domains were defined as frail. The occurrence of postoperative complications (Clavien and Dindo grade 2 or higher) within 30 days after the surgery was assessed as the outcome. The predictive value of CGA was evaluated using crosstab and logistic regression analysis and compared to that of other risk stratification systems, including modified Frailty Index-5, -11, and American Society of Anesthesiologists Physical Classification System.

RESULTS

A total of 261 patients were included in the study, and 25 (9.6%) patients were assigned to the "frail" group. There were 27 (10.3%) patients with a postoperative complication (general: n = 20, 7.7%, surgical: n = 7, 2.7%) within postoperative 30 days. Patients with a complication showed significantly more deficits on preoperative CGA than those without complications (P = 0.004). On multivariate logistic regression analysis, frailty based on CGA (odds ratio = 3.51, P = 0.031) and the modified Frailty Index-11 (odds ratio = 3.13, P = 0.038) were associated with the occurrence of general complications.

CONCLUSION

Frailty based on CGA was significantly associated with early general complications following surgery for lumbar spinal stenosis in patients older than 65 years.

LEVEL OF EVIDENCE

2.

CHA2DS2-VASc score, cerebral small vessel disease, and frailty in older patients with atrial fibrillation

The CHA₂DS₂-VASc score is a validated predictor of ischemic stroke in atrial fibrillation (AF) patients. However, data are limited on whether the CHA₂DS₂-VASc score is associated with subclinical brain structural changes or physical frailty among older AF patients. We assessed the relationship between CHA₂DS₂-VASc scores and brain structural changes or physical frailty in AF patients without history of stroke. Overall, 117 patients completed a comprehensive geriatric assessment for physical frailty. In brain magnetic resonance imaging sub-study (n = 49), brain volume and white matter hyperintensity lesion burden were automatically quantified using the LESIONQUANT software program. Patients with high risk of CHA₂DS₂-VASc scores (≥ 2 in men or ≥ 3 in women) tended to be older and had more comorbidities, higher frailty index, and slower gait speed. Total white matter hyperintensity lesion burden was higher in those with high risk of CHA₂DS₂-VASc score than in those with intermediate risk (score of 1 in men or 2 in women) of CHA₂DS₂-VASc score (1.67 [interquartile range: 0.70–3.45] vs. 0.64 [0.19–1.44], p = 0.036). Cognitive function was associated with brain volume, but gait speed was related with white matter hyperintensity lesion burden. In conclusion, we showed a positive relationship between CHA₂DS₂-VASc scores, white matter hyperintensity lesion burden, and physical frailty in older AF patients. Subclinical brain changes associated with high CHA₂DS₂-VASc scores may predict physical frailty risk.

Serum Tau Proteins as Potential Biomarkers for the Assessment of Alzheimer's Disease Progression

Total tau (t-tau) and phosphorylated tau (p-tau) protein elevations in cerebrospinal fluid (CFS) are well-established hallmarks of Alzheimer’s disease (AD), while the associations of serum t-tau and p-tau levels with AD have been inconsistent across studies. To identify more accessible non-invasive AD biomarkers, we measured serum tau proteins and associations with cognitive function in age-matched controls (AMC, n = 26), mild cognitive impairment group (MCI, n = 30), and mild-AD group (n = 20) according to the Mini-mental State Examination (MMSE), Clinical Dementia Rating (CDR), and Global Deterioration Scale (GDS) scores. Serum t-tau, but not p-tau, was significantly higher in the mild-AD group than AMC subjects (p < 0.05), and there were significant correlations of serum t-tau with MMSE and GDS scores. Receiver operating characteristic (ROC) analysis distinguished mild-AD from AMC subjects with moderate sensitivity and specificity (AUC = 0.675). We speculated that tau proteins in neuronal cell-derived exosomes (NEX) isolated from serum would be more strongly associated with brain tau levels and disease characteristics, as these exosomes can penetrate the blood-brain barrier. Indeed, ELISA and Western blotting indicated that both NEX t-tau and p-tau (S202) were significantly higher in the mild-AD group compared to AMC (p < 0.05) and MCI groups (p < 0.01). In contrast, serum amyloid β (Aβ_1–42) was lower in the mild-AD group compared to MCI groups (p < 0.001). During the 4-year follow-up, NEX t-tau and p-tau (S202) levels were correlated with the changes in GDS and MMSE scores. In JNPL3 transgenic (Tg) mice expressing a human tau mutation, t-tau and p-tau expression levels in NEX increased with neuropathological progression, and NEX tau was correlated with tau in brain tissue exosomes (tEX), suggesting that tau proteins reach the circulation via exosomes. Taken together, our data suggest that serum tau proteins, especially NEX tau proteins, are useful biomarkers for monitoring AD progression.

A medical care model using comprehensive geriatric assessment for community-dwelling older Korean adults

BACKGROUND

The quality of life of older adults deteriorates when they lose their ability to perform activities of daily living. Therefore, the older adults should be assessed to identify risk factors for functional decline and to correct these factors so that they may live as independently as possible in the community. We developed a medical care model using comprehensive geriatric assessment (CGA) for community-dwelling older patients.

METHODS

Three hundred and ninety-one older adults who were frail or likely to be frail were selected. CGA was performed before and after the interventions to determine the effect of the interventions. Three interventions-exercise training, nutritional education, and medication reconciliation-were performed for 5.1 ± 0.6 months.

RESULTS

A comparison of the results of the first and second assessments revealed that the participants showed improvement in physical function, quality of life, medication, and nutrition. The average gait speed had increased from 0.77 ± 0.17 m/s to 0.89 ± 0.20 m/s (P < 0.001). For health-related quality of life, the average EuroQol-5 dimension-3L score for each domain decreased significantly. The number of patients with polypharmacy decreased from 181(50 %) to 155(43 %) (P = 0.001). The number of patients who were at risk of malnutrition or malnourished decreased from 72(20 %) to 45(12 %) (P < 0.001). The majority of participants were highly satisfied and were willing to participate again.

CONCLUSION

Our medical model based on CGA showed a significantly positive effect on the physical function and quality of life of community-dwelling older adults. Our model may be a promising strategy for improving the care of them.

Association between preoperative use of antithrombotic medications and intraoperative transfusion in older patients undergoing cancer surgery

BACKGROUND

Management of antiplatelet agents and other chronic anticoagulation medications in patients scheduled for surgery can reduce intraoperative bleeding complications. However, few studies on the association of antithrombotics, relative to their duration of action, with intraoperative transfusion have been conducted. We aimed to determine the association of recent use of antithrombotics, relative to their duration of action, with intraoperative transfusion in elderly people undergoing cancer surgery.

METHODS

The study subjects were patients aged 65 years or older who were scheduled for cancer surgery and presented for comprehensive geriatric assessment. We reviewed the baseline patient characteristics obtained from electronic medical records and the patients' preoperative medication history, including anticoagulants, antiplatelet agents, and streptokinase/streptodornase.

RESULTS

A total of 475 cancer patients were included. Multivariate analysis showed that long-acting anticoagulant therapy before surgery was a significant risk factor for intraoperative transfusion. Long-acting anticoagulants increased the risk of transfusion approximately 15.9-fold (95% CI 1.9-136.2). The attributable risk of long-acting anticoagulants to transfusion was approximately 93.7%. Also, low body mass index (BMI) and hepato-pancreato-biliary (HPB) surgery were significantly associated with intraoperative transfusion. The adjusted odds ratios for low BMI (<18.5 kg/m²) and HPB surgery (reference: lower gastrointestinal surgery) were 5.3 (95% CI 1.8-15.4) and 4.9 (95% CI 1.9-12.5), respectively.

CONCLUSIONS

It was found that the perioperative use of long-acting anticoagulants was associated with an increased risk of intraoperative transfusion, further highlighting the importance of medication optimization for elderly patients with cancer surgery.

Association of pre-operative medication use with unplanned 30-day hospital readmission after surgery in oncology patients receiving comprehensive geriatric assessment

BACKGROUND

This study aimed to determine whether pre-operative medication use is associated with unplanned 30-day readmission in elderly people undergoing cancer surgery.

METHODS

Patients aged 65 years or older who were scheduled for cancer surgery and presented for comprehensive geriatric assessment were included. Comparisons of variables between patients with readmission and those without readmission were performed by univariate and multivariate analyses.

RESULTS

A total of 473 patients were included. Multivariate analysis showed that pre-operative discontinuation-requiring medications (PDRMs) and gastrointestinal/hepato-pancreato-biliary (GI/HPB) cancer were significant factors for 30-day readmission. PDRM increased the risk of readmission by about 2.2-fold. Attributable risk of PDRM to readmission was around 55%. The adjusted odds ratio and attributable risk for GI/HPB surgery was 3.4 (95% CI 1.0-11.5) and 70.8%, respectively.

CONCLUSIONS

Medication use has an impact on unplanned 30-day readmission in geriatric oncology patients, further highlighting the importance of medication optimization for elderly patients with cancer surgery.

Prospective Validation of The Korean Cancer Study Group Geriatric Score (KG)-7, a Novel Geriatric Screening Tool, in Older Patients with Advanced Cancer Undergoing First-line Palliative Chemotherapy

Purpose

The purpose of this study was to prospectively validate the Korean Cancer Study Group Geriatric Score (KG)-7, a novel geriatric screening tool, in older patients with advanced cancer planned to undergo first-line palliative chemotherapy.

Materials and Methods

Participants answered the KG-7 questionnaire before undergoing geriatric assessment (GA) and first-line palliative chemotherapy. The performance of KG-7 was evaluated by calculating the sensitivity (SE), specificity (SP), positive and negative predictive value (PPV and NPV), balanced accuracy (BA), and area under the curve (AUC).

Results

The baseline GA and KG-7 results were collected from 301 patients. The median age was 75 years (range, 70 to 93 years). Abnormal GA was documented in 222 patients (73.8%). Based on the ≤ 5 cut-off value of KG-7 for abnormal GA, abnormal KG-7 score was shown in 200 patients (66.4%). KG-7 showed SE, SP, PPV, NPV, and BA of 75.7%, 59.7%, 84.4%, 46.0%, and 67.7%, respectively; AUC was 0.745 (95% confidence interval, 0.687 to 0.803). Furthermore, patients with higher KG-7 scores showed significantly longer survival (p=0.006).

Conclusion

KG-7 appears to be adequate in identifying patients with abnormal GA prospectively. Hence, KG-7 can be a useful screening tool for Asian countries with limited resources and high patient volume.

Predicting cumulative incidence of adverse events in older patients with cancer undergoing first-line palliative chemotherapy: Korean Cancer Study Group (KCSG) multicentre prospective study

Background

Older patients have increased risk of toxicity from chemotherapy. Current prediction tools do not provide information on cumulative risk.

Methods

Patients aged ≥ 70 years with solid cancer were prospectively enrolled. A prediction model was developed for adverse events (AEs) ≥ Grade 3 (G3), based on geriatric assessment (GA), laboratory, and clinical variables.

Results

301 patients were enrolled (median age, 75 years). Median number of chemotherapy cycles was 4. During first-line chemotherapy, 53.8% of patients experienced AEs ≥ G3. Serum protein < 6.7 g/dL, initial full-dose chemotherapy, psychological stress or acute disease in the past 3 months, water consumption < 3 cups/day, unable to obey a simple command, and self-perception of poor health were significantly related with AEs ≥ G3. A predicting model with these six variables ranging 0–8 points was selected with the highest discriminatory ability (c-statistic= 0.646), which could classify patients into four risk groups. Predicted cumulative incidence of AEs ≥ G3 was discriminated according to risk groups.

Conclusions

This prediction tool could identify the risk of AEs ≥ G3 after chemotherapy and provide information on the cumulative incidence of AEs in each cycle.

Clinical Trial Id

WHO ICTRP number, KCT0001071

Court rulings involving individuals with dementia in Israel: A qualitative perspective

Background

Individuals with dementia may appear before the courts in different roles. Despite the growing interest in the rights of older persons with dementia, relatively little empirical data exist regarding their actual interactions and experiences in court.

Methods

This study used a qualitative, textual analysis methodology. A total of 281 Israeli legal court cases, which addressed issues relating to dementia, were analyzed.

Results

Four key themes were found in the legal texts: (1) The legal construction of dementia and its relationships to old age; (2) The importance of procedural justice; (3) The implications and outcomes of the legal process; and (4) The legal implications to the society as a whole.

Conclusions

The legal narratives, which surround legal cases that deal with dementia in Israel, reveal an internal tension between stigmatic and anti-stigmatic narratives. This complex reality raises the need for further research and for a clearer judicial policy.

Is Frailty a Modifiable Risk Factor of Future Adverse Outcomes in Elderly Patients with Incident End-Stage Renal Disease?

Little is known about the clinical significance of frailty and changes of frailty after dialysis initiation in elderly patients with end-stage renal disease (ESRD). We prospectively enrolled 46 elderly patients with incident ESRD at a dialysis center of a tertiary hospital between May 2013 and March 2015. Frailty was assessed by using a comprehensive geriatric assessment protocol and defined as a multidimensional frailty score of ≥ 10. The main outcome was the composite of all-cause death or cardiovascular hospitalization, as determined in June 2016. The median age of the 46 participants was 71.5 years, and 63.0% of them were men. During the median 17.7 months follow-up, the rate of composite outcome was 17.4%. In multivariate logistic regression analysis, after adjusting for age, sex, diabetes, body mass index (BMI), and time of predialytic nephrologic care, female sex, and increased BMI were associated with increased and decreased odds of frailty, respectively. In multivariate Cox proportional hazards analysis, after adjusting for age, sex, diabetes, BMI, and time of predialytic nephrologic care, frailty was significantly associated with the composite adverse outcome. In repeated frailty assessments, the multidimensional frailty score significantly improved 12 months after the initiation of dialysis, which largely relied on improved nutrition. Therefore, frailty needs to be assessed for risk stratification in elderly patients with incident ESRD.

Preoperative medication use and its association with postoperative length of hospital stay in surgical oncology patients receiving comprehensive geriatric assessment

AIM

The present study aimed to investigate whether preoperative medication use is associated with postoperative length of hospital stay in older adults undergoing cancer surgery.

METHODS

Patients aged ≥65 years who were scheduled for cancer surgery and presented for preoperative comprehensive geriatric assessment were included in the present study. Cognitive function evaluation and preoperative medication review were carried out, as well as baseline characteristics of participants collected from electronic medical records. The primary efficacy variable was the postoperative length of stay (LOS) in hospital.

RESULTS

A total of 475 cancer patients were included for the analysis. Baseline characteristics of participants including older age, lower body mass index (BMI) and male sex were associated with longer postoperative stay. Among the clinical variables, cancer type, number of medications, potentially inappropriate medication (PIM) and delirium-inducing medication were found as statistically significant factors for postoperative LOS. In multivariate analysis, variables independently associated with postoperative LOS were cancer type, PIM use, BMI, and the number of medications after controlling for age, BMI, sex, cancer type, the number of medications, PIM, and delirium-inducing medication. In subgroup analysis of gastrointestinal cancer, multiple linear regression analysis showed that PIM use and BMI were significantly associated with LOS after adjustment for age, sex, and number of medication.

CONCLUSIONS

The present study supports the impact of medication use on postoperative LOS in geriatric oncology patients. The results add a further aspect to medication optimization in older patients undergoing cancer surgery. Geriatr Gerontol Int 2018; 18: 12-19.

Prediction of Mortality and Postoperative Complications using the Hip-Multidimensional Frailty Score in Elderly Patients with Hip Fracture

High mortality and dependent living after hip fracture pose a significant public health concern. Retrospective study was conducted with 481 hip fracture patients (≥65 years of age) undergoing surgery from March 2009 to May 2014. The Hip-MFS was calculated by Comprehensive Geriatric Assessment (CGA). The primary outcome was the 6-month all-cause mortality rate. The secondary outcomes were 1-year all-cause mortality, postoperative complications and prolonged hospital stay, and institutionalization. Thirty-five patients (7.3%) died within 6 months after surgery (median [interquartile range], 2.9 [1.4-3.9] months). The fully adjusted hazard ratio per 1 point increase in Hip-MFS was 1.458 (95% confidence interval [CI]: 1.210-1.758) for 6-months mortality and odds ratio were 1.239 (95% CI: 1.115-1.377), 1.156 (95% CI: 1.031-1.296) for postoperative complications and prolonged total hospital stay, respectively. High-risk patients (Hip-MFS > 8) showed higher risk of 6-month mortality (hazard ratio: 3.545, 95% CI: 1.466-8.572) than low-risk patients after adjustment. Hip-MFS successfully predict 6-month mortality, postoperative complications and prolonged hospital stay in elderly hip fracture patients after surgery. Hip-MFS more precisely predict 6-month mortality than age or existing tools (P values of comparison of ROC curve: 0.002, 0.004, and 0.044 for the ASA classification, age and NHFS, respectively).

The Prevalence and Incidence of Dementia Due to Alzheimer's Disease: a Systematic Review and Meta-Analysis

BACKGROUND

Updated information on the epidemiology of dementia due to Alzheimer's disease (AD) is needed to ensure that adequate resources are available to meet current and future healthcare needs. We conducted a systematic review and meta-analysis of the incidence and prevalence of AD.

METHODS

The MEDLINE and EMBASE databases were searched from 1985 to 2012, as well as the reference lists of selected articles. Included articles had to provide an original population-based estimate for the incidence and/or prevalence of AD. Two individuals independently performed abstract and full-text reviews, data extraction and quality assessments. Random-effects models were employed to generate pooled estimates stratified by age, sex, diagnostic criteria, location (i.e., continent) and time (i.e., when the study was done).

RESULTS

Of 16,066 abstracts screened, 707 articles were selected for full-text review. A total of 119 studies met the inclusion criteria. In community settings, the overall point prevalence of dementia due to AD among individuals 60+ was 40.2 per 1000 persons (CI95%: 29.1-55.6), and pooled annual period prevalence was 30.4 per 1000 persons (CI95%: 15.6-59.1). In community settings, the overall pooled annual incidence proportion of dementia due to AD among individuals 60+ was 34.1 per 1000 persons (CI95%: 16.4-70.9), and the incidence rate was 15.8 per 1000 person-years (CI95%: 12.9-19.4). Estimates varied significantly with age, diagnostic criteria used and location (i.e., continent).

CONCLUSIONS

The burden of AD dementia is substantial. Significant gaps in our understanding of its epidemiology were identified, even in a high-income country such as Canada. Future studies should assess the impact of using such newer clinical diagnostic criteria for AD dementia such as those of the National Institute on Aging-Alzheimer's Association and/or incorporate validated biomarkers to confirm the presence of Alzheimer pathology to produce more precise estimates of the global burden of AD.

Depression in the Family of Patients With Dementia in Korea

INTRODUCTION

Dementia is the leading cause of disability worldwide in the elderly individuals. Although prior studies have examined psychiatric symptoms in dementia caregivers, few studies have examined physician-diagnosed depression in the family caregiver of a patient with dementia.

METHODS

We used data from 457 864 respondents from the Korea Community Health Survey. We used logistic regression to examine the relationship between physician-diagnosed depression and cohabitation with a patient with dementia.

RESULTS

Cohabitation with a patient with dementia (1.2% of the Korean population) was significantly associated with physician-diagnosed depression. The significance remained in females when the data were stratified by sex. A significant association also occurred among males with low family income.

CONCLUSION

To reduce the burden of dementia, we need a management policy that includes the caregiver as well as the patient with dementia. In particular, political management for the vulnerable population, male caregiver in low-income family and female caregiver in high-income family, should be prepared.

Reducing the Burden of Dementia in Korea

There has been a dramatic increase in the number of persons with dementia in Korea, and the number is expected to continue to increase. Dementia is increasingly a condition for which there are effective treatments and services. Because most adults work full-time in addition to having other family responsibilities, the government of Korea and the community are more involved in helping persons with dementia, than in the past. Nurses are needed to help with dementia research, public policy, education, and healthcare in Korea and elsewhere.

The effect of telemedicine on cognitive decline in patients with dementia

Introduction Telemedicine has the advantage of providing medical resources in rural areas, but few studies have been conducted to investigate its efficacy in dementia care, compared to face-to-face care. This study evaluated the effectiveness of telemedicine in relation to cognitive changes in patients with dementia. Methods We evaluated cognitive changes over time, according to care modality, in 188 patients with dementia who were registered at our university-based dementia clinic. We followed 98 patients using telemedicine services and 90 patients who attended the dementia clinic in person. Patients in the telemedicine group also visited a public health center located in a rural area about 50 km from the dementia clinic. Results Changes in the mean annualized Mini-Mental State Examination (MMSE) score were not significantly different between the telemedicine group and the face-to-face dementia clinic group ( p = 0.291), with changes of 0.60 and 1.03 points, respectively. However, cognitive decline was significantly lower in the telemedicine group for the less severe initial cognitive performance subgroup than more severe cognitive performance subgroup ( p = 0.049), with changes of 0.62 and 1.59 points, respectively. Higher initial Clinical Dementia Rating (CDR) scores, MMSE scores, and age were found to be independent predictive factors of subsequent cognitive changes, as indicated by mean annualized MMSE scores. Discussion These findings suggest that telemedicine may be a useful alternative to face-to-face clinical visits for management of dementia in patients who are located in rural areas.

Association of pre-operative medication use with post-operative delirium in surgical oncology patients receiving comprehensive geriatric assessment

BACKGROUND

Older patients undergoing surgery tend to have a higher frequency of delirium. Delirium is strongly associated with poor surgical outcomes. This study evaluated the association between pre-operative medication use and post-operative delirium (POD) in surgical oncology patients receiving comprehensive geriatric assessment (CGA).

METHODS

A total of 475 patients who were scheduled for cancer surgery and received CGA from January 2014 to June 2015 were included. Pre-operative medication review through CGA was conducted on polypharmacy (≥5 medications), delirium-inducing medications (DIMs), fall-inducing medications (FIMs), and potentially inappropriate medications (PIMs). POD was confirmed by psychiatric consultation, and DSM-V criteria were used for diagnosing delirium. The model fit of the prediction model was assessed by computing the Hosmer-Lemeshow goodness-of-fit test. Effect size was measured using the Nagelkerke R(2). Discrimination of the model was assessed by an analysis of the area under receiver operating curve (AUROC).

RESULTS

Two models were constructed for multivariate analysis based on univariate analysis; model I included dementia and DIM in addition to age and sex, and model II included PIM instead of DIM of model I. Every one year increase of age increased the risk of POD by about 1.1-fold. DIM was a significant factor for POD after adjusting for confounders (AOR 12.78, 95 % CI 2.83-57.74). PIM was also a significant factor for POD (AOR 5.53, 95 % CI 2.03-15.05). The Hosmer-Lemeshow test results revealed good fits for both models (χ(2) = 3.842, p = 0.871 for model I and χ(2) = 8.130, p = 0.421 for model II). The Nagelkerke R(2) effect size and AUROC for model I was 0.215 and 0.833, respectively. Model II had the Nagelkerke R(2)effect size of 0.174 and AUROC of 0.819.

CONCLUSIONS

These results suggest that pharmacists' comprehensive review for pre-operative medication use is critical for the post-operative outcomes like delirium in older patients.

The Prevalence and Incidence of Frontotemporal Dementia: a Systematic Review

Background

Population-based prevalence and incidence studies are essential for understanding the burden of frontotemporal dementia (FTD).

Methods

The MEDLINE and EMBASE databases were searched to identify population-based publications from 1985 to 2012, addressing the incidence and/or prevalence of FTD. References of included articles and prior systematic reviews were searched for additional studies. Two reviewers screened all abstracts and full-text reviews, abstracted data and performed quality assessments.

Results

Twenty-six studies were included. Methodological limitations led to wide ranges in the estimates for prevalence (point prevalence 0.01-4.6 per 1000 persons; period prevalence 0.16-31.04 per 1000 persons) and incidence (0.0-0.3 per 1000 person-years). FTD accounted for an average of 2.7% (range 0-9.1%) of all dementia cases among prevalence studies that included subjects 65 and older compared to 10.2% (range 2.8-15.7%) in studies restricted to those aged less than 65. The cumulative numbers of male (373 [52.5%]) and female (338 [47.5%]) cases from studies reporting this information were nearly equal (p=0.18). The behavioural variant FTD (bvFTD) was almost four times as common as the primary progressive aphasias.

Conclusions

Population-based estimates for the epidemiology of FTD varied widely in the included studies. Refinements in the diagnostic process, possibly by the use of validated biomarkers or limiting case ascertainment to specialty services, are needed to obtain more precise estimates of the prevalence and incidence of FTD.

The Prevalence and Incidence of Dementia: a Systematic Review and Meta-analysis

Introduction

Dementia is a common neurological condition affecting many older individuals that leads to a loss of independence, diminished quality of life, premature mortality, caregiver burden and high levels of healthcare utilization and cost. This is an updated systematic review and meta-analysis of the worldwide prevalence and incidence of dementia.

Methods

The MEDLINE and EMBASE databases were searched for relevant studies published between 2000 (1985 for Canadian papers) and July of 2012. Papers selected for full-text review were included in the systematic review if they provided an original population-based estimate for the incidence and/or prevalence of dementia. The reference lists of included articles were also searched for additional studies. Two individuals independently performed abstract and full-text review, data extraction, and quality assessment of the papers. Random-effects models and/or meta-regression were used to generate pooled estimates by age, sex, setting (i.e., community, institution, both), diagnostic criteria utilized, location (i.e., continent) and year of data collection.

Results

Of 16,066 abstracts screened, 707 articles were selected for full-text review. A total of 160 studies met the inclusion criteria. Among individuals 60 and over residing in the community, the pooled point and annual period prevalence estimates of dementia were 48.62 (CI95%: 41.98-56.32) and 69.07 (CI95%: 52.36-91.11) per 1000 persons, respectively. The respective pooled incidence rate (same age and setting) was 17.18 (CI95%: 13.90-21.23) per 1000 person-years, while the annual incidence proportion was 52.85 (CI95%: 33.08-84.42) per 1,000 persons. Increasing participant age was associated with a higher dementia prevalence and incidence. Annual period prevalence was higher in North America than in South America, Europe and Asia (in order of decreasing period prevalence) and higher in institutional compared to community and combined settings. Sex, diagnostic criteria (except for incidence proportion) and year of data collection were not associated with statistically significant different estimates of prevalence or incidence, though estimates were consistently higher for females than males.

Conclusions

Dementia is a common neurological condition in older individuals. Significant gaps in knowledge about its epidemiology were identified, particularly with regard to the incidence of dementia in low- and middle-income countries. Accurate estimates of prevalence and incidence of dementia are needed to plan for the health and social services that will be required to deal with an aging population.

Frailty as a Predictor of Acute Kidney Injury in Hospitalized Elderly Patients: A Single Center, Retrospective Cohort Study

BACKGROUND

Elderly patients have an increased risk for acute kidney injury (AKI). However, few studies have reported on predictors for AKI in geriatric patients. Therefore, we aimed at determining the effect of frailty as a predictor of AKI.

METHODS

We retrospectively enrolled 533 hospitalized elderly patients (aged ≥ 65 years) who had their creatinine levels measured (≥ 1 measurement) during admission for a period of 1 year (2013) and conducted a comprehensive geriatric assessment (CGA) within 1 year before the index hospitalization. We examined five variables (activity of daily living [ADL] and instrumental ADL dependence, dementia, nutrition, and polypharmacy) from CGA. We categorized the patients into 3 groups according to the tertile of aggregate frailty scores: Group 1, score 1-2; Group 2, score 3-4; Group 3, score 5-8).

RESULTS

Fifty-four patients (10.1%) developed AKI (median duration, 4 days). The frailest group (Group 3) showed an increased risk of AKI as compared to Group 1, (hazard ratio [HR] = 3.536, P = 0.002). We found that discriminatory accuracy for AKI improved with the addition of the tertile of aggregate frailty score to covariates (area under the receiver operator characteristics curves [AUROC] 0.641, AUROC 0.739, P = 0.004). Forty-six patients (8.6%) were transferred to nursing facilities and 477 patients (89.5%) were discharged home. The overall 90-day and 1-year mortality for elderly inpatients were 7.9% and 26.3%. The frailest group also demonstrated an increased risk of discharge to nursing facilities, and 90-day and 1-year mortality as compared to Group 1, independent of AKI severity (nursing facilities: odd ratio = 4.843, P = 0.002; 90-day mortality: HR = 6.555, P = 0.002; 1-year mortality: HR = 3.249, P = 0.001).

CONCLUSIONS

We found that frailty may independently predict the development of AKI and adverse outcomes in geriatric inpatients.

Plasma soluble neuregulin-1 as a diagnostic biomarker for Alzheimer's disease

To identify some apparent biomarker candidates for the diagnosis of Alzheimer's disease (AD) pathology, we investigated whether there would be a significant difference between the levels of the plasma proteins of AD patients and healthy people. A total of 115 subjects were enrolled, 60 individuals with AD and 55 healthy controls. There was a statistical difference in the mini-mental status exam (MMSE) scores and the clinical dementia rating (CDR) scores between the two groups. We used the immunoblotting assay to analyze several plasma proteins in the subjects. Amyloid-β (Aβ), S100a9, and soluble neuregulin-1 (sNRG-1), including α-synuclein (α-Syn) as a detection control were detected in the plasma samples. Unlike Aβ, S100a9 and α-Syn, the level of sNRG-1 of the AD patients was significantly higher than that of the healthy control subjects. The AD patients were divided into mild and moderate groups according to their MMSE and CDR scores. We found a significant correlation between the level of sNRG-1 and MMSE scores. The sNRG-1 level was significantly higher in mild AD patients as well as in moderate AD patients compared with that of the control subjects. These new findings indicate that increased plasma sNRG-1 levels might be a novel and reliable biological marker for the early diagnosis of AD.

Mini-Mental State Examination (MMSE) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations

BACKGROUND

The Mini Mental State Examination (MMSE) is a cognitive test that is commonly used as part of the evaluation for possible dementia.

OBJECTIVES

To determine the diagnostic accuracy of the Mini-Mental State Examination (MMSE) at various cut points for dementia in people aged 65 years and over in community and primary care settings who had not undergone prior testing for dementia.

SEARCH METHODS

We searched the specialised register of the Cochrane Dementia and Cognitive Improvement Group, MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), LILACS (BIREME), ALOIS, BIOSIS previews (Thomson Reuters Web of Science), and Web of Science Core Collection, including the Science Citation Index and the Conference Proceedings Citation Index (Thomson Reuters Web of Science). We also searched specialised sources of diagnostic test accuracy studies and reviews: MEDION (Universities of Maastricht and Leuven, www.mediondatabase.nl), DARE (Database of Abstracts of Reviews of Effects, via the Cochrane Library), HTA Database (Health Technology Assessment Database, via the Cochrane Library), and ARIF (University of Birmingham, UK, www.arif.bham.ac.uk). We attempted to locate possibly relevant but unpublished data by contacting researchers in this field. We first performed the searches in November 2012 and then fully updated them in May 2014. We did not apply any language or date restrictions to the electronic searches, and we did not use any methodological filters as a method to restrict the search overall.

SELECTION CRITERIA

We included studies that compared the 11-item (maximum score 30) MMSE test (at any cut point) in people who had not undergone prior testing versus a commonly accepted clinical reference standard for all-cause dementia and subtypes (Alzheimer disease dementia, Lewy body dementia, vascular dementia, frontotemporal dementia). Clinical diagnosis included all-cause (unspecified) dementia, as defined by any version of the Diagnostic and Statistical Manual of Mental Disorders (DSM); International Classification of Diseases (ICD) and the Clinical Dementia Rating.

DATA COLLECTION AND ANALYSIS

At least three authors screened all citations.Two authors handled data extraction and quality assessment. We performed meta-analysis using the hierarchical summary receiver-operator curves (HSROC) method and the bivariate method.

MAIN RESULTS

We retrieved 24,310 citations after removal of duplicates. We reviewed the full text of 317 full-text articles and finally included 70 records, referring to 48 studies, in our synthesis. We were able to perform meta-analysis on 28 studies in the community setting (44 articles) and on 6 studies in primary care (8 articles), but we could not extract usable 2 x 2 data for the remaining 14 community studies, which we did not include in the meta-analysis. All of the studies in the community were in asymptomatic people, whereas two of the six studies in primary care were conducted in people who had symptoms of possible dementia. We judged two studies to be at high risk of bias in the patient selection domain, three studies to be at high risk of bias in the index test domain and nine studies to be at high risk of bias regarding flow and timing. We assessed most studies as being applicable to the review question though we had concerns about selection of participants in six studies and target condition in one study.The accuracy of the MMSE for diagnosing dementia was reported at 18 cut points in the community (MMSE score 10, 14-30 inclusive) and 10 cut points in primary care (MMSE score 17-26 inclusive). The total number of participants in studies included in the meta-analyses ranged from 37 to 2727, median 314 (interquartile range (IQR) 160 to 647). In the community, the pooled accuracy at a cut point of 24 (15 studies) was sensitivity 0.85 (95% confidence interval (CI) 0.74 to 0.92), specificity 0.90 (95% CI 0.82 to 0.95); at a cut point of 25 (10 studies), sensitivity 0.87 (95% CI 0.78 to 0.93), specificity 0.82 (95% CI 0.65 to 0.92); and in seven studies that adjusted accuracy estimates for level of education, sensitivity 0.97 (95% CI 0.83 to 1.00), specificity 0.70 (95% CI 0.50 to 0.85). There was insufficient data to evaluate the accuracy of the MMSE for diagnosing dementia subtypes.We could not estimate summary diagnostic accuracy in primary care due to insufficient data.

AUTHORS' CONCLUSIONS

The MMSE contributes to a diagnosis of dementia in low prevalence settings, but should not be used in isolation to confirm or exclude disease. We recommend that future work evaluates the diagnostic accuracy of tests in the context of the diagnostic pathway experienced by the patient and that investigators report how undergoing the MMSE changes patient-relevant outcomes.

A Novel Geriatric Screening Tool in Older Patients with Cancer: The Korean Cancer Study Group Geriatric Score (KG)-7

Geriatric assessment (GA) is resource-consuming, necessitating screening tools to select appropriate patients who need full GA. The objective of this study is to design a novel geriatric screening tool with easy-to-answer questions and high performance objectively selected from a large dataset to represent each domain of GA. A development cohort was constructed from 1284 patients who received GA from May 2004 to April 2007. Items representing each domain of functional status, cognitive function, nutritional status, and psychological status in GA were selected according to sensitivity (SE) and specificity (SP). Of the selected items, the final questions were chosen by a panel of oncologists and geriatricians to encompass most domains evenly and also by feasibility and use with cancer patients. The selected screening questions were validated in a separate cohort of 98 cancer patients. The novel screening tool, the Korean Cancer Study Group Geriatric Score (KG)-7, consisted of 7 items representing each domain of GA. KG-7 had a maximal area under the curve (AUC) of 0.93 (95% confidence interval (CI) 0.92−0.95) in the prediction of abnormal GA, which was higher than that of G-8 (0.87, 95% CI 0.85–0.89) within the development cohort. The cut-off value was decided at ≤ 5 points, with a SE of 95.0%, SP of 59.2%, positive predictive value (PPV) of 85.3%, and negative predictive value (NPV) of 82.6%. In the validation cohort, the AUC was 0.82 (95% CI 0.73−0.90), and the SE, SP, PPV, and NPV were 89.5%, 48.6%, 77.3%, and 75.0%, respectively. Furthermore, patients with higher KG-7 scores showed significantly longer overall survival (OS) in the development and validation cohorts. In conclusions, the KG-7 showed high SE and NPV to predict abnormal GA. The KG-7 also predicted OS. Given the results of our studies, the KG-7 could be used effectively in countries with high patient burden and low resources to select patients in need of full GA and intervention.

Incidence of and risk factors for Alzheimer's disease and mild cognitive impairment in Korean elderly

BACKGROUND/AIMS

Knowledge of incidence rates and risk factors is essential for the development of strategies to treat patients with Alzheimer's disease (AD) and mild cognitive impairment (MCI).

METHODS

A subpopulation of the Nationwide Survey on Dementia Epidemiology (460 Korean subjects aged ≥65 years from 2 rural and 2 urban districts) was followed up for 3.5 years. The age-specific incidence was estimated and risk factors were identified.

RESULTS

The age-standardized incidence of AD and MCI was 7.9 and 28.1 cases per 1,000 person-years, respectively. MCI was associated with a 6-fold increased risk of AD. Depression was a risk factor for AD with MCI. Age, lack of formal education, illiteracy, rural residence, and marital status were associated with the risk of AD.

CONCLUSION

Strategies to control modifiable risk factors should be implemented to decrease the incidence of AD.

Prediction of Postoperative Complications Using Multidimensional Frailty Score in Older Female Cancer Patients with American Society of Anesthesiologists Physical Status Class 1 or 2

BACKGROUND

Even low-risk, elderly patients are at increased risk for postoperative morbidity compared with their younger counterparts. We sought to evaluate the role of a scoring model in predicting adverse surgical outcomes in low-risk, older, female cancer patients.

STUDY DESIGN

From October 2011 to May 2014, two hundred and eighty-one low-risk female patients (aged 65 years and older, American Society of Anesthesiologists class 1 or 2) undergoing curative cancer surgery were included. The Multidimensional Frailty Score (MFS) was calculated by comprehensive geriatric assessment. The primary end point was postoperative complication (eg, pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned ICU admission). Secondary outcomes were length of hospital stay and institutionalization.

RESULTS

Twenty patients experienced postoperative complications and 15 patients were discharged to nursing facilities. The fully adjusted odds ratio (OR) per 1-point increase in MFS was 1.412 (95% CI, 1.012-1.969; p = 0.042) for postoperative complications, 1.377 (95% CI, 0.935-2.026; p = 0.105) for institutionalization, and 1.411 (95% CI, 1.110-1.793; p = 0.005) for prolonged hospital stay. The high-risk group (MFS ≥7) showed an increased risk for postoperative complications (OR = 8.513; 95% CI, 2.210-32.785; p = 0.002), institutionalization (OR = 1.291; 95% CI, 0.324-5.152; p = 0.717), and prolonged hospital stay (OR = 2.336; 95% CI, 1.090-5.006; p = 0.029) compared with the low-risk group (MFS <7), after adjusting confounders.

CONCLUSIONS

Multidimensional Frailty Score based on a preoperative comprehensive geriatric assessment is useful for predicting postoperative complications and prolonged hospital stay, even in low-risk elderly women who are undergoing cancer surgery.

The effect of telemedicine on the duration of treatment in dementia patients

We studied 442 patients who met the DSM-IV-TR criteria for dementia and whose treatment was initiated at the Kangwon National University Hospital (KNUH) in Chuncheon. Over a five-year period, there were 259 patients who regularly visited the KNUH dementia clinic in person, and 168 patients who received medical services from the dementia clinic via telemedicine. The telemedicine patients attended a public health centre in Hongcheon, a facility located in a rural area about 50 km south east of the KNUH. The mean treatment duration was significantly longer for the telemedicine group than for the clinical visit group (P < 0.001), with durations of 26.6 and 14.6 months, respectively. Low Clinical Dementia Rating scores (hazard ratio = 1.47, 95% confidence interval = 1.26-1.71) and use of telemedicine (hazard ratio = 0.55, 95% confidence interval = 0.42-0.72) were found to be independent predictive factors of increased treatment duration. These findings suggest that telemedicine may be useful in slowing disease progression in dementia patients in rural areas.

Prevalence and trends of dementia in Korea: a systematic review and meta-analysis

Through a systematic review and meta-analysis of epidemiological studies on dementia, we assessed the prevalence of dementia and its subtypes-Alzheimer' disease (AD) and vascular dementia (VaD)-in Korea. We searched for epidemiological studies on dementia published in 1990-2013 using PubMed, Scopus, EMBASE, KoreaMed, KISS, and RiCH. Dementia prevalence in elderly patients (aged≥65 yr) was 9.2% (95% confidence interval [CI], 8.2%-10.4%) from 11 studies, which was higher than those from Western and other Asian countries. AD was the most prevalent dementia type, with a prevalence of 5.7% (95% CI, 5.0%-6.4%) from 10 studies compared with 2.1% (95% CI, 1.6%-2.7%) for VaD from 9 studies. The age-specific prevalence of dementia approximately doubled with each 5.8-yr increase of age. Although a significant increasing trend of dementia prevalence was not observed, it increased slightly from 7.3% to 8.7% after 2005; AD prevalence increased after 1995 and VaD prevalence decreased after the early 2000s. The AD/VaD ratio increased from 1.96 in the early 1990s to 4.13 in the 2010s, similar to the worldwide ratio. Owing to this high prevalence in the aging population, dementia will impose significant economic burdens to Korean society.

Global epidemiology of dementia: Alzheimer's and vascular types

The prevalence of dementia varies substantially worldwide. This is partially attributed to the lack of methodological uniformity among studies, including diagnostic criteria and different mean population ages. However, even after considering these potential sources of bias, differences in age-adjusted dementia prevalence still exist among regions of the world. In Latin America, the prevalence of dementia is higher than expected for its level of population aging. This phenomenon occurs due to the combination of low average educational attainment and high vascular risk profile. Among developed countries, Japan seems to have the lowest prevalence of dementia. Studies that evaluated the immigration effect of the Japanese and blacks to USA evidenced that acculturation increases the relative proportion of AD cases compared to VaD. In the Middle East and Africa, the number of dementia cases will be expressive by 2040. In general, low educational background and other socioeconomic factors have been associated with high risk of obesity, sedentarism, diabetes, hypertension, dyslipidemia, and metabolic syndrome, all of which also raise the risk of VaD and AD. Regulating these factors is critical to generate the commitment to make dementia a public health priority.

The early discontinuation of palliative chemotherapy in older patients with cancer

PURPOSE

Older patients with cancer may have an increased risk of early discontinuation of active treatment (ED), which results in poor outcome in curative or adjuvant settings. We aimed to determine the association between survival and ED and to identify predictors of ED in palliative setting.

METHODS

Ninety-eight patients older than 65 years of age who received a comprehensive geriatric assessment (CGA) before palliative first-line chemotherapy were analyzed. Clinical information and CGA results were retrieved from electronic medical record. CGA included Charlson's co-morbidity index, activities of daily living (ADL), instrumental ADL (IADL), Mini-Mental Status Examination, short-form of the geriatric depression scale, timed-get-up-and-go test (TGUG), and mini-nutritional assessment (MNA). ED was defined as no active cancer treatment (radiotherapy and/or chemotherapy) beyond palliative first-line chemotherapy. Predictors of ED were identified using clinical parameters and CGA.

RESULTS

Active treatment was discontinued after first-line chemotherapy in 30 patients during median follow-up period of 15.1 months. ED after first-line chemotherapy was associated with shorter overall survival (OS; median OS = 3.1 vs. 14.7 months in patients with ED compared with patients without ED, p < 0.001). Eastern Cooperative Oncology Group performance status, living alone, ADL, IADL, MNA, and TGUG were associated with ED (p = 0.001, p = 0.048, p = 0.001, p < 0.001, p < 0.001, p = 0.002, respectively). In multivariable analysis, malnutrition and dependent IADL were the independent predictive factors for ED (odds ratio = 5.03; 95 % confidence interval = 1.50-16.87: odds ratio = 3.06; confidence interval = 1.03-9.12, respectively).

CONCLUSIONS

ED was associated with shorter OS in older patients with cancer. Malnutrition and dependent IADL were identified as independent predictive factors for ED.

Comprehensive geriatric assessment can predict postoperative morbidity and mortality in elderly patients undergoing elective surgery

The proportion of elderly patients who undergo surgery has rapidly increased; however, clinical indicators predicting outcomes are limited. Our aim was to evaluate the significance of comprehensive geriatric assessment (CGA) in elderly patients undergoing elective surgery. We studied 141 consecutive elderly patients (age: 78.0±6.5 years old, male: 41.1%) who were referred to our geriatric department for surgical risk evaluation. CGA was performed to evaluate physical health, functional status, psychological health, and social support. The primary composite outcome of this study was in-hospital death or post-discharge institutionalization. In-hospital adverse events, such as delirium, pressure ulcers, pneumonia, and urinary tract infections, were also evaluated. The associations between CGA and in-hospital adverse events, in-hospital death, and post-discharge institutionalization were investigated. There were 32 adverse outcomes (6 in-hospital deaths and 26 post-discharge institutionalizations). Compared with the patients who were discharged to their homes, patients with adverse outcomes were characterized by poor nutritional status and prior strokes. However, there was no significant difference in surgical risk or anesthesia type. The CGA results showed that patients with adverse outcomes were associated with functional dependency and poor nutrition. The cumulative number of impairments in the CGA domain was significantly associated with adverse outcomes, in-hospital events, and prolonged hospital stays. In multiple logistic regression analysis, cumulative impairment in CGA was independently associated with surgical outcomes in elderly patients undergoing elective surgery. Preoperative CGA can identify elderly patients at greater risk for mortality, post-discharge institutionalization, adverse in-hospital events, and prolonged length of hospital stay.

Prevalence of dementia and dementing diseases in the old-old population in Japan: the Kurihara Project. Implications for Long-Term Care Insurance data

BACKGROUND

There have been no reports on the prevalence of dementia among the old-old people in Japan.

METHODS

We studied the old-old population in Kurihara, northern Japan. Analysis 1 of Participants 1 (n=590) was performed to evaluate the prevalence of dementia and dementing diseases by intensive evaluation including MRI. Analysis 2 aimed to determine a good indicator for detecting 'suspected dementia condition' based on the Long-Term Care Insurance index. Analysis 3 of Participants 2 (n=3915) aimed to estimate the prevalence of 'suspected dementia condition'.

RESULTS

In Analysis 1, 73 people (12.4%) were diagnosed with dementia. The most common cause was Alzheimer's disease with cerebrovascular disease. In Analysis 2, level I of the Impairment Level of Dementia was found to be a good indicator of 'suspected dementia condition'. In Analysis 3, the overall estimated prevalence of 'suspected dementia condition' was 23.6%. In men, the ratio increased gradually from 75 to 87 years old to about 20%, increased to 40% at the age of 88 and became stable thereafter. In contrast, in women, the ratio increased from 75 to 95+ years old, reaching about 70%.

CONCLUSIONS

The prevalence was higher than that reported previously. There was a difference between the sexes: an 'age-related' increase occurred in men and an 'ageing-related' increase in women. Alzheimer's disease with cerebrovascular disease was the most common cause, which coincided with the previous findings of individuals aged 65 years and older; however, the ratio of mixed dementia was greater.

[Epidemiology of dementia in elderly living in the 3rd borough of Bangui (Central African Republic)]

Given the gradual improvement of living conditions and aging, dementia and related syndromes are becoming serious problems in the developing countries. A cross-sectional door to door type study in neighbourhood, was conducted from October 2008 to January 2009, in the general population in Bangui, order to help get a better understanding of the prevalence and risk factors of dementia among people over 65 living in the Central African capital. Of the 496 elderly respondents, 188 had cognitive disorders. After a neuropsychological examination, 40 of these subjects were diagnosed with dementia. The prevalence of dementia was 8.1% (IC 95% = [5.7-10.5]). The average age of subjects with dementia, ranging from 65 to 90 years, was 76.0 ± 7.1 years. There was a significant risk of developing dementia for an increase of ten years old (OR = 2.6, 95% CI [1.5 to 4.5]). The sex-ratio was 6/34. 82.5% of the demented had never attended school. 70.0% showed a state of malnutrition (BMI ≤ 18,5 kg/m(2)), significantly associated with dementia (OR = 3.3; IC 95% = [1.5-7.3]). The blood pressure was high in 67.5% of demented which is significantly associated with dementia (OR = 2.4; IC 95% = [1.1-5.4]). A recent change in financial status was a factor significantly associated with dementia (OR = 6.4; IC 95% = [1.8-22.5]). These results support the existence of dementia in urban Africa. The observed prevalence is close to those found in high-income countries. Further studies should be conducted which includes both the rural and urban Africa, to better understand the problem and solutions consider to comprehensive care and prevention axes adapted to our context.

Restless legs syndrome in older people: a community-based study on its prevalence and association with major depressive disorder in older Korean adults

OBJECTIVE

The prevalence of restless legs syndrome (RLS) and its relationship with the demographic variables in an older Korean population were examined.

METHODS

A face-to-face household survey was conducted in five different regions of Korea from June 2008 to August 2008. Among a total of 3074 individuals who were aged more than 65, 1990 participants were interviewed, and the response rate was 64.7%. The diagnosis of RLS was made using an RLS questionnaire. The medical review of systems was assessed by a self-report questionnaire containing 15 items. Depression was diagnosed with the diagnostic section of depressive disorder of the Korean version of the Composite International Diagnostic Interview (CIDI) and the short form of the Geriatric Depression Scale (GDS).

RESULTS

The prevalence of RLS in the older Korean population was 9.5% (men, 7.1%; women, 11.3%). RLS had a significant association with anemia (odds ratio (OR), 1.66; 95% confidence interval (CI), 1.29-2.12; P < 0.001) and renal diseases (OR, 2.57; 95% CI, 1.95-3.38; P < 0.001). RLS seemed to have a significant relationship with depression by using the CIDI (adjusted OR 2.01; 95% CI, 1.45-2.79. P < 0.001) and GDS (adjusted OR, 1.62; 95% CI, 1.34-1.94; P < 0.001).

CONCLUSIONS

Restless legs syndrome might be a risk factor for major depressive disorder in older Koreans. Future investigations should focus on the causality and mechanism underlying the relationship between RLS and major depressive disorder.

Prevalence of dementia and its correlates among participants in the National Early Dementia Detection Program during 2006-2009

OBJECTIVE

To investigate the prevalence of dementia and its correlates among people with poor socioeconomic status, poor social support systems, and poor performance on the Korean version of the Mini-Mental Status Exam (MMSE-KC).

METHODS

We used 2006-2009 data of the National Early Dementia Detection Program (NEDDP) conducted on Jeju Island. This program included all residents >65 years old who were receiving financial assistance. We examined those who performed poorly (standard deviation from the norm of <-1.5) on the MMSE-KC administered as part of the NEDDP, using age-, gender-, and education-adjusted norms for Korean elders. A total of 1708 people were included in this category.

RESULTS

The prevalence of dementia in this group was 20.5%. Multivariate logistic regression analysis revealed that the following factors were statistically significantly associated with dementia: age of 80 or older, no education, nursing home residence, and depression.

CONCLUSION

The prevalence of dementia is very high among those with lower MMSE-KC scores, and significant correlates include older age, no education, living in a nursing home, and depression. Enhancing lifetime education to improve individuals' cognitive reserves by providing intellectually challenging activities, encouraging living at home rather than in a nursing home, and preventing and treating depression in its early phase could reduce the prevalence of dementia in this population.