Behavioral Disturbances, Not Cognitive Deterioration, Are Associated With Altered Food Selection in Seniors With Alzheimer's Disease

Medium-Chain Triglycerides (MCTs) for the Symptomatic Treatment of Dementia-Related Diseases: A Systematic Review

Pathomechanisms of dementias involve increasing damage to neuronal energy metabolism, resulting in degeneration-related insulin resistance and glucose hypometabolism. In this case, ketone bodies can provide an alternative energy source. Supplementation with medium-chain triglycerides (MCTs), which can induce ketogenesis, may alleviate brain energy deficits and improve neuronal function. This review aims to determine the effectiveness of MCT as a symptomatic treatment approach. The systematic literature search was conducted in April 2023 following the Cochrane Handbook and PRISMA guidelines. A total of 21 studies were included, comprising eight uncontrolled trials and 13 RCTs investigating the effects of MCT on Alzheimer's disease (AD) and mild cognitive impairment (MCI). A substantial increase in plasma ketone levels and brain metabolic rates was observed. Cognitive assessments showed only occasional or domain-specific performance improvements. The effects on functional abilities or psychological outcomes have been inadequately studied. Besides gastrointestinal side effects, no harmful effects were observed. However, the evidence was severely weakened by heterogeneous and poorly designed study protocols, bias, and conflicts of interest. In conclusion, the ketogenic properties of MCTs may have beneficial effects on brain metabolism in AD and MCI but do not always result in measurable clinical improvement. Current evidence is insufficient to recommend MCT as a comparable symptomatic treatment option.

Malnutrition and neuropsychiatric symptoms in dementia: the Cache County Dementia Progression Study

OBJECTIVES

Among people with dementia, poor nutritional status has been associated with worse cognitive and functional decline, but few studies have examined its association with neuropsychiatric symptoms (NPS). We examined this topic in a population-based sample of persons with dementia.

DESIGN

Longitudinal, observational cohort study.

SETTING

Community.

PARTICIPANTS

Two hundred ninety-two persons with dementia (71.9% Alzheimer's disease, 56.2% women) were followed up to 6 years.

MEASUREMENTS

We used a modified Mini-Nutritional Assessment (mMNA) and the Neuropsychiatric Inventory (NPI) to evaluate nutritional status and NPS, respectively. Individual linear mixed effects models examined the associations between time-varying mMNA total score or clinical categories (malnourishment, risk for malnourishment, or well-nourished) and NPI total score (excluding appetite domain) or NPI individual domain or cluster (e.g. psychosis) scores. Covariates tested were dementia onset age, type, and duration, medical comorbidities, sex, apolipoprotein E (APOE) genotype, and education.

RESULTS

Compared to the well-nourished, those at risk for malnourishment and those malnourished had higher total NPI scores [b (95% CI) = 1.76 (0.04, 3.48) or 3.20 (0.62, 5.78), respectively], controlling for significant covariates. Higher mMNA total score (better nutritional status) was associated with lower total NPI [b (95% CI) = -0.58 (-0.86, -0.29)] and lower domain scores for psychosis [b (95% CI) = -0.08 (-0.16, .004)], depression [b (95% CI = -0.11 (-0.16, -0.05], and apathy [b (95% CI = -0.19 (-0.28, -0.11)].

CONCLUSIONS

Worse nutritional status is associated with more severe NPS. Dietary or behavioral interventions to prevent malnutrition may be beneficial for persons with dementia.

Mining microbes for mental health: Determining the role of microbial metabolic pathways in human brain health and disease

There is increasing knowledge regarding the role of the microbiome in modulating the brain and behaviour. Indeed, the actions of microbial metabolites are key for appropriate gut-brain communication in humans. Among these metabolites, short-chain fatty acids, tryptophan, and bile acid metabolites/pathways show strong preclinical evidence for involvement in various aspects of brain function and behaviour. With the identification of neuroactive gut-brain modules, new predictive tools can be applied to existing datasets. We identified 278 studies relating to the human microbiota-gut-brain axis which included sequencing data. This spanned across psychiatric and neurological disorders with a small number also focused on normal behavioural development. With a consistent bioinformatics pipeline, thirty-five of these datasets were reanalysed from publicly available raw sequencing files and the remainder summarised and collated. Among the reanalysed studies, we uncovered evidence of disease-related alterations in microbial metabolic pathways in Alzheimer's Disease, schizophrenia, anxiety and depression. Amongst studies that could not be reanalysed, many sequencing and technical limitations hindered the discovery of specific biomarkers of microbes or metabolites conserved across studies. Future studies are warranted to confirm our findings. We also propose guidelines for future human microbiome analysis to increase reproducibility and consistency within the field.

Efficacy of Mealtime Interventions for Malnutrition and Oral Intake in Persons With Dementia: A Systematic Review

Malnutrition and weight loss are highly prevalent in persons with Alzheimer's disease and related dementias. Oral intake is an important interventional target for addressing these nutritional consequences. However, the efficacy of interventions remains poorly understood as prior syntheses have failed to examine the impact of intervention approaches on malnutrition and hypothesized mechanisms of action in persons with dementia. This review aimed to determine the efficacy of mealtime interventions to improve oral intake and nutritional outcomes in persons with dementia. Four databases yielded 1712 studies, resulting in 32 studies that met inclusion criteria. Studies included education, environmental modifications, feeding, oral supplementation, and other pharmacologic/ecopsychological interventions. While the majority of studies reported statistically significant improvements in at least 1 nutritional outcome, study design and outcome measures were heterogenous with many lacking adequate statistical power or blinding. Collectively, we found moderate evidence to suggest the efficacy of oral supplementation, and preliminary evidence to suggest that feeding interventions, education, and environmental modifications may confer improvements. Findings clarify the state of existing evidence regarding various interventional strategies for improving malnutrition in persons with dementia. While some approaches are promising, adequately powered and rigorously designed multidimensional intervention trials are needed to inform clinical decision-making in real-world contexts.

Diet quality is associated with malnutrition and low calf circumference in Canadian long-term care residents

Background

Older adults living in long-term care (LTC) are nutritionally vulnerable. The purpose of this study was to determine diet quality of Canadian LTC residents and its association with malnutrition and low calf circumference.

Methods

A cross-sectional study was undertaken in 32 LTC homes across four Canadian provinces. Nutrient adequacy ratios (NARs) were calculated for seventeen nutrients; mean adequacy ratio (MAR) was calculated to describe overall diet quality. Malnutrition risk was assessed with the Mini Nutritional Assessment-Short Form (MNA-SF) and diagnosis of protein/energy malnutrition with the Patient-Generated Subjective Global Assessment (PG-SGA). Calf circumference (CC) was also assessed. Linear and logistic regressions for these outcomes with diet quality as the predictor were conducted adjusting for covariates.

Results

Average MNA-SF score was 10.7 ± 2.5. Residents (43.5%) had mild/moderate to severe malnutrition based on the PG-SGA and 32.6% had a CC of < 31 cm. Mean MAR score was 0.79 ± 0.09 with significant differences between those requiring eating assistance (0.77 ± 0.11) and those that did not require assistance (0.80 ± 0.07) (p < .05). MAR score was significantly associated with malnutrition in fully adjusted models: MNA-SF scores [β = 5.34, 95% Confidence interval (CI) (2.81, 7.85)] and PG-SGA [Odds ratio (OR) = 0.49, 95% CI (0.38, 0.64)]. Those who had better diet quality were more likely to be well nourished or not at risk. Although several individual nutrients were associated with low CC (< 31 cm), there was no association between overall diet quality (MAR) and low CC.

Conclusions

Diet quality is associated with malnutrition and individual nutrients (NARs) with a low CC. In addition to calories and protein, nutrient dense diets that promote adequate micronutrient intake are required in LTC.

Impact of Cognition and Handfeeding Assistance on Nutritional Intake for Nursing Home Residents

In nursing homes (NHs), residents are at risk for malnutrition and weight loss. The purpose of this secondary data analysis was to examine the impact of resident cognitive status and level of feeding assistance provided by NH staff on resident's daily nutritional intake and body weight. As part of a large, multisite clinical trial (N = 786), residents with and without dementia were examined according to level of feeding assistance required during mealtimes (independent, set-up only, needs help eating) over a 21-day period. Outcomes analyzed were percent of meal intake by meal type (breakfast, lunch, dinner) and overall daily intake (meals + snacks/supplements). Residents with dementia who required meal set-up assistance had significantly lower meal intake for all three meals. Residents without dementia requiring meal set-up assistance experienced significantly lower intake for breakfast and dinner, but not lunch. When snacks and supplements were offered between meals, residents with dementia consumed approximately 163 additional calories/day, and residents without dementia consumed approximately 156 additional calories/day. This study adds new evidence that residents at greatest risk for low intake are those who are only provided set-up assistance for meals and/or have cognitive impairment.

Cholecystokinin and Alzheimer's disease: a biomarker of metabolic function, neural integrity, and cognitive performance

Cholecystokinin (CCK) is a satiety hormone that is highly expressed in brain regions like the hippocampus. CCK is integral for maintaining or enhancing memory and thus may be a useful marker of cognitive and neural integrity in participants with normal cognition, mild cognitive impairment, and Alzheimer's disease (AD). Cerebrospinal fluid (CSF) CCK levels were examined in 287 subjects from the Alzheimer's Disease Neuroimaging Initiative. Linear or voxelwise regression was used to examine associations between CCK, regional gray matter, CSF AD biomarkers, and cognitive outcomes. Briefly, higher CCK was related to a decreased likelihood of having mild cognitive impairment or AD, better global and memory scores, and more gray matter volume primarily spanning posterior cingulate cortex, parahippocampal gyrus, and medial prefrontal cortex. CSF CCK was also strongly related to higher CSF total tau (R² = 0.342) and p-tau-181 (R² = 0.256) but not Aβ1-42. Tau levels partially mediated CCK and cognition associations. In conclusion, CCK levels may reflect compensatory protection as AD pathology progresses.

Appetite, Metabolism and Hormonal Regulation in Normal Ageing and Dementia

Feeding and nutrition follow the growth trajectory of the course of life. The profound physiological changes that human body experiences during ageing affect separate aspects of food intake, from tastant perception to satiety. Concurrent morbidities, such as neurodegeneration, as seen in dementia, and metabolic syndrome, may further shape nutritional behaviours, status and adequacy. In an effort to fill the gap between the exhausting basic research and the actual needs of professionals caring for the exponentially expanding ageing population, the current review addresses major factors relevant to appetite and eating disturbances. Does age alter the perception of food modalities? Is food generally still perceived as alluring and delicious with age? Is there an interplay between ageing, cognitive decline, and malnutrition? What tools can we adopt for proper and timely monitoring? Finally, what anatomical and pathophysiological evidence exists to support a hypothesis of central regulation of metabolic perturbations in normal and accelerated cognitive impairment, and how can we benefit from it in health practice?

Tube Feeding Patients With Dementia

As the population ages, the incidence of dementia increases. All types of dementia, whether they are reversible or irreversible, lead to loss of intellectual function and judgment, memory impairment, and personality changes. The skills to feed oneself, use eating utensils, and consume items recognized as food, thereby maintaining nutrition status, may be lost as dementia progresses. Reports indicate that nutrition status may be maintained when patients are hand fed, but this is labor intensive and therefore expensive. Feeding via a percutaneous endoscopic gastrostomy tube is often chosen as an acceptable alternative. Research indicates that there is little benefit in this population when aggressive nutrition support is instituted. Providing tube feeding to patients with dementia does not necessarily extend life, increase weight, or reduce the incidence of pressure ulcers or aspiration. There are many legal and ethical issues involved in the decision to place a feeding tube in demented patients. The primary issue in patients with dementia may be autonomy and the right of an individual to decide whether or not a tube should be placed at all. Legally, there is clear precedent that the courts see the insertion of a feeding tube as extraordinary care that the patient has the right to refuse. However, much of case law is derived from cases of patients who were in a persistent vegetative state. Advance directives help to determine what the patient would want for himself. Considering all the options before the patient can no longer make decisions is the most desirable course.

Making the Most of Mealtimes (M3): protocol of a multi-centre cross-sectional study of food intake and its determinants in older adults living in long term care homes

BACKGROUND

Older adults living in long term care (LTC) homes are nutritionally vulnerable, often consuming insufficient energy, macro- and micronutrients to sustain their health and function. Multiple factors are proposed to influence food intake, yet our understanding of these diverse factors and their interactions are limited. The purpose of this paper is to fully describe the protocol used to examine determinants of food and fluid intake among older adults participating in the Making the Most of Mealtimes (M3) study.

METHODS

A conceptual framework that considers multi-level influences on mealtime experience, meal quality and meal access was used to design this multi-site cross-sectional study. Data were collected from 639 participants residing in 32 LTC homes in four Canadian provinces by trained researchers. Food intake was assessed with three-days of weighed food intake (main plate items), as well as estimations of side dishes, beverages and snacks and compared to the Dietary Reference Intake. Resident-level measures included: nutritional status, nutritional risk; disease conditions, medication, and diet prescriptions; oral health exam, signs of swallowing difficulty and olfactory ability; observed eating behaviours, type and number of staff assisting with eating; and food and foodservice satisfaction. Function, cognition, depression and pain were assessed using interRAI LTCF with selected items completed by researchers with care staff. Care staff completed a standardized person-directed care questionnaire. Researchers assessed dining rooms for physical and psychosocial aspects that could influence food intake. Management from each site completed a questionnaire that described the home, menu development, food production, out-sourcing of food, staffing levels, and staff training. Hierarchical regression models, accounting for clustering within province, home and dining room will be used to determine factors independently associated with energy and protein intake, as proxies for intake. Proportions of residents at risk of inadequate diets will also be determined.

DISCUSSION

This rigorous and comprehensive data collection in a large and diverse sample will provide, for the first time, the opportunity to consider important modifiable factors associated with poor food intake of residents in LTC. Identification of factors that are independently associated with food intake will help to develop effective interventions that support food intake.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02800291 , retrospectively registered June 7, 2016.

Evaluation of the Relationship between Nutritional Status and Quality of Life among Nursing Home Residents with Alzheimer's Disease

The purpose of this study was to determine nutritional status and its influence on their quality of life in Alzheimer's disease (AD) patients with Mini Nutritional Assessment (MNA) and anthropometric measurements. This study was conducted with 57 Alzheimer type dementia patients between the ages of 52 and 89 who live in nursing homes in Ankara/Turkey. In this study, it was found that the 57.9% of the AD patients were at risk of malnutrition, and that 19.3% were malnourished. Malnutrition risk rises as the length of stay increases (p< .05). A significant correlation between body weight and quality of life as well as one between calf circumference and quality of life was detected (p< .05). In this study, nutrient intake among aged individuals with AD was found unbalanced; a statistically significant correlation between energy / nutrient intake and quality of life also was not detected.

Effectiveness of different memory training programs on improving hyperphagic behaviors of residents with dementia: a longitudinal single-blind study

BACKGROUND

Hyperphagia increases eating-associated risks for people with dementia and distress for caregivers. The purpose of this study was to compare the long-term effectiveness of spaced retrieval (SR) training and SR training combined with Montessori activities (SR + M) for improving hyperphagic behaviors of special care unit residents with dementia.

METHODS

The study enrolled patients with dementia suffering from hyperphagia resident in eight institutions and used a cluster-randomized single-blind design, with 46 participants in the SR group, 49 in the SR + M group, and 45 participants in the control group. For these three groups, trained research assistants collected baseline data on hyperphagic behavior, pica, changes in eating habits, short meal frequency, and distress to caregivers. The SR and SR + M groups underwent memory training over a 6-week training period (30 sessions), and a generalized estimating equation was used to compare data of all the three groups of subjects obtained immediately after the training period and at follow-ups 1 month, 3 months, and 6 months later.

RESULTS

Results showed that the hyperphagic and pica behaviors of both the SR and SR + M groups were significantly improved (P<0.001) and that the effect lasted for 3 months after training. The improvement of fast eating was significantly superior in the SR + M group than in the SR group. The improvement in distress to caregivers in both intervention groups lasted only until the posttest. Improvement in changes in eating habits of the two groups was not significantly different from that of the control group.

CONCLUSION

SR and SR + M training programs can improve hyperphagic behavior of patients with dementia. The SR + M training program is particularly beneficial for the improvement of rapid eating. Caregivers can choose a suitable memory training program according to the eating problems of their residents.

Nutritional status according to the stages of Alzheimer's disease

OBJECTIVE

To assess the nutritional status of Alzheimer's disease (AD) patients with no other associated dementia, according to disease stage.

DESIGN

Cross-sectional observational study.

SETTING

Neurobehavioral Diseases Outpatient Clinic, Clinical Hospital, Ribeirao Preto Medical School (University of São Paulo).

PARTICIPANTS

The sample consisted of 36 individuals of both genders with AD diagnosis, and no other associated type of dementia, in various stages of the disease, according to the Clinical Dementia Rating (CDR 0.5-3).

MEASUREMENTS

Nutritional status was evaluated using the Mini Nutritional Assessment (MNA) and anthropometric measurements such as weight, body mass index (BMI) and arm, waist, abdomen and hip circumferences. In addition, body composition was assessed by bioelectrical impedance analysis (BIA).

RESULTS

The mean age of the group was 74.2 ± 10.1 years, 72.2 % of them were women. The MNA showed that most of these individuals were at risk for malnutrition (55.5 %) and many of them (43.7 %) were underweight according to BMI. Data from BIA analysis revealed that 41.7 % of these individuals had a quantity of body fat classified as malnutrition and 11.1 % had a phase angle (PA) below recommended values for age group. There was a negative and significant correlation of lean mass and PA with age, and of global MNA evaluation with CDR, as well as a positive correlation of MNA total score with fat mass and BMI. Worse classifications of nutritional status obtained by MNA scores were also observed in the more severe stages of the disease, according to the CDR.

CONCLUSION

Patients with AD are mostly elderly with changes in body composition that are typical of aging, with signs of peripheral malnutrition and preservation of abdominal fat. However, greater impairment of general nutritional status was observed in the more advanced stages of AD, creating a situation of greater vulnerability for these patients.

Vitamin D and neurocognitive function

In recent years, emerging evidence has linked vitamin D not only to its known effects on calcium and bone metabolism, but also to many chronic illnesses involving neurocognitive decline. The importance of vitamin D₃ in reducing the risk of these diseases continues to increase due to the fact that an increasing portion of the population in developed countries has a significant vitamin D deficiency. The older population is at an especially high risk for vitamin D deficiency due to the decreased cutaneous synthesis and dietary intake of vitamin D. Recent studies have confirmed an association between cognitive impairment, dementia, and vitamin D deficiency. There is a need for well-designed randomized trials to assess the benefits of vitamin D and lifestyle interventions in persons with mild cognitive impairment and dementia.

Nutritional status among older residents with dementia in open versus special care units in municipal nursing homes: an observational study

Background

Undernutrition is widespread among institutionalised elderly, and people suffering from dementia are at particularly high risk. Many elderly with dementia live in open units or in special care units in nursing homes. It is not known whether special care units have an effect on the nutritional status of the residents. The aim of this study was therefore to examine the nutritional status of residents with dementia in both open units and in special care units.

Methods

Among Oslo’s 29 municipal nursing homes, 21 participated with 358 residents with dementia or cognitive impairment, of which 46% lived in special care units. Nutritional status was assessed using the Malnutrition Universal Screening Tool and anthropometry.

Results

We found no differences (p > 0.05) in risk of undernutrition, body mass index, mid-upper arm muscle circumference or triceps skinfold thickness between residents in open units and those in special care units. Residents in special care units were significantly younger and stronger when measured with a hand-grip test.

Conclusions

We found no difference in nutritional status between nursing home residents with dementia/cognitive impairment in open units versus in special care units.

Impaired satiation and increased feeding behaviour in the triple-transgenic Alzheimer's disease mouse model

Alzheimer's disease (AD) is associated with non-cognitive symptoms such as changes in feeding behaviour that are often characterised by an increase in appetite. Increased food intake is observed in several mouse models of AD including the triple transgenic (3×TgAD) mouse, but the mechanisms underlying this hyperphagia are unknown. We therefore examined feeding behaviour in 3×TgAD mice and tested their sensitivity to exogenous and endogenous satiety factors by assessing food intake and activation of key brain regions. In the behavioural satiety sequence (BSS), 3×TgAD mice consumed more food after a fast compared to Non-Tg controls. Feeding and drinking behaviours were increased and rest decreased in 3×TgAD mice, but the overall sequence of behaviours in the BSS was maintained. Exogenous administration of the satiety factor cholecystokinin (CCK; 8–30 µg/kg, i.p.) dose-dependently reduced food intake in Non-Tg controls and increased inactive behaviour, but had no effect on food intake or behaviour in 3×TgAD mice. CCK (15 µg/kg, i.p.) increased c-Fos protein expression in the supraoptic nucleus of the hypothalamus, and the nucleus tractus solitarius (NTS) and area postrema of the brainstem to the same extent in Non-Tg and 3×TgAD mice, but less c-Fos positive cells were detected in the paraventricular hypothalamic nucleus of CCK-treated 3×TgAD compared to Non-Tg mice. In response to a fast or a period of re-feeding, there was no difference in the number of c-Fos-positive cells detected in the arcuate nucleus of the hypothalamus, NTS and area postrema of 3×TgAD compared to Non-Tg mice. The degree of c-Fos expression in the NTS was positively correlated to food intake in Non-Tg mice, however, this relationship was absent in 3×TgAD mice. These data demonstrate that 3×TgAD mice show increased feeding behaviour and insensitivity to satiation, which is possibly due to defective gut-brain signalling in response to endogenous satiety factors released by food ingestion.

Health and nutrition promotion program for patients with dementia (NutriAlz): cluster randomized trial

OBJECTIVE

To assess the effectiveness of health and nutrition program (NutriAlz) versus usual care on functional level in elderly people with dementia living at home, as well as on clinical practice related to nutrition and on the caregiver's burden.

DESIGN

Cluster randomized multi-centre study with one-year follow-up.

SETTING

11 Alzheimer outpatients and day care centres (Barcelona, Spain).

PARTICIPANTS

Nine hundred and forty six home-living Alzheimer patients with identified caregiver were consecutively recruited (intervention group: 6 centres, 448 patients vs control group: 5 centres, 498 patients).

INTERVENTION

The intervention was a teaching and training intervention on health and nutrition program, NutriAlz, directed both to physician and main caregiver, as well as persons affected by Alzheimer's disease or other dementias, including a standardised protocol for feeding and nutrition.

MAIN OUTCOME MEASURES

The main outcome measure was the reduction in the loss of autonomy (Activities of daily living (ADL/IADL) scales) assessed at 6 and 12 months. Secondary outcomes measures were Improvement in nutritional status (Mini Nutritional Assessment (MNA), BMI, and weight changes), and caregiver burden (Zarit scale).

RESULTS

The one-year assessment was completed for 293 patients (65.4%) in the intervention group and 363 patients (72.9%) in the control group (usual care). The annual rate of ADL change was -0.83 vs -0.62 (p=0.984), and the caregiver's subjective burden 0.59 vs 2.36 (p=0.681) in intervention and control group, respectively. MNA, however, showed an improvement (+0.46 vs -0.66, p=0.028), suggesting an effective nutritional behaviour.

CONCLUSION

The NutriAlz program had no effect on functional decline in Alzheimer disease patients living at home over one year, but reduced the risk for malnutrition, as recommendations concerning diet and exercise were provided.

Neuronutrition and Alzheimer's disease

Alzheimer's disease (AD) is a complex neurological disorder resulting from both genetic and environmental factors with the latter being particularly important for the sporadic form of the disease. As such, diets rich in saturated fatty acids and alcohol, and deficient in antioxidants and vitamins appear to promote the onset of the disease, while diets rich in unsaturated fatty acids, vitamins, antioxidants, and wine likely suppress its onset. In addition, evidence suggests that diets rich in polyphenols and some spices suppress the onset of AD by scavenging free radicals and preventing oxidative damage. Metal ions are known to catalyze the production of free radicals and induce mental retardation or dementia, and several studies have also identified metals such as Pb, Fe, Al, Cu, and Zn in AD pathogenesis. While specific metal chelators have been tested for therapy, they have not been very successful, probably due to their late administration, i.e., after brain damage has been triggered. Since several dietary polyphenols are known to chelate metals, their routine use may also be protective against the onset of AD. In this review, we summarize beneficial dietary techniques in the fight against AD.

[Approach to dysphagia in advanced dementia]

From the onset, dementia affects the patient's nutritional status, producing anorexia, weight loss, feeding apraxia and dysphagia. Distinct strategies are required in each of the stages of this disease, starting with awareness and knowledge of the problem and its prompt detection. In dementia, dysphagia usually appears in advanced phases, when the patient is often institutionalized. When dysphagia is suspected, the patient's tolerance must be evaluated by the volume/viscosity test, environmental and postural strategies should be introduced, and the texture of the diet should be modified. This is a complex task requiring the involvement of a properly trained interdisciplinary team, able to provide information and alternatives and integrate the family environment in the patient's care. The adapted diet should be based on the traditional diet that can also be combined with artificial supplements to provide a varied diet that increases patients', caregivers' and relatives' satisfaction. Tube feeding has shown no nutritional benefits in patients with advanced dementia. Therefore, we propose assisted oral feeding as the most natural and appropriate form of feeding in these patients, always respecting their previously expressed wishes.

Study of the ketogenic agent AC-1202 in mild to moderate Alzheimer's disease: a randomized, double-blind, placebo-controlled, multicenter trial

BACKGROUND

Alzheimer's disease (AD) is characterized by early and region-specific declines in cerebral glucose metabolism. Ketone bodies are produced by the body during glucose deprivation and are metabolized by the brain. An oral ketogenic compound, AC-1202, was tested in subjects with probable AD to examine if ketosis could improve cognitive performance.

METHODS

Daily administration of AC-1202 was evaluated in 152 subjects diagnosed with mild to moderate AD in a US-based, 90-day, randomized, double-blind, placebo-controlled, parallel-group study. Subjects were on a normal diet and continued taking approved AD medications. Primary cognitive end points were mean change from Baseline in the AD Assessment Scale-Cognitive subscale (ADAS-Cog), and global scores in the AD Cooperative Study - Clinical Global Impression of Change (ADCS-CGIC). AC-1202 was compared to Placebo in several population groups, including: intention-to-treat (ITT), per protocol, and dosage compliant groups. Results were also stratified by APOE4 carriage status (a predefined analysis based on the epsilon 4 (E4) variant of the apolipoprotein E gene). This trial was registered with ClinicalTrials.gov, registry number NCT00142805, information available at http://clinicaltrials.gov/ct2/show/NCT00142805

RESULTS

AC-1202 significantly elevated a serum ketone body (beta-hydroxybutyrate) 2 hours after administration when compared to Placebo. In each of the population groups, a significant difference was found between AC-1202 and Placebo in mean change from Baseline in ADAS-Cog score on Day 45: 1.9 point difference, p = 0.0235 in ITT; 2.53 point difference, p = 0.0324 in per protocol; 2.6 point difference, p = 0.0215 in dosage compliant. Among participants who did not carry the APOE4 allele (E4(-)), a significant difference was found between AC-1202 and Placebo in mean change from Baseline in ADAS-Cog score on Day 45 and Day 90. In the ITT population, E4(-) participants (N = 55) administered AC-1202 had a significant 4.77 point difference in mean change from Baseline in ADAS-Cog scores at Day 45 (p = 0.0005) and a 3.36 point difference at Day 90 (p = 0.0148) compared to Placebo. In the per protocol population, E4(-) participants receiving AC-1202 (N = 37) differed from placebo by 5.73 points at Day 45 (p = 0.0027) and by 4.39 points at Day 90 (p = 0.0143). In the dosage compliant population, E4(-) participants receiving AC-1202 differed from placebo by 6.26 points at Day 45 (p = 0.0011, N = 38) and 5.33 points at Day 90 (p = 0.0063, N = 35). Furthermore, a significant pharmacologic response was observed between serum beta-hydroxybutyrate levels and change in ADAS-Cog scores in E4(-) subjects at Day 90 (p = 0.008). Adverse events occurred more frequently in AC-1202 subjects, were primarily restricted to the gastrointestinal system, and were mainly mild to moderate in severity and transient in nature.

CONCLUSION

AC-1202 rapidly elevated serum ketone bodies in AD patients and resulted in significant differences in ADAS-Cog scores compared to the Placebo. Effects were most notable in APOE4(-) subjects who were dosage compliant.

Aggression in persons with dementia: use of nursing theory to guide clinical practice

With approximately four million people in the United States today diagnosed with dementia, one of the most devastating problems faced by caregivers and patients is dealing with aggressive behavior. Aggression occurs in half of persons diagnosed with dementia and is associated with more rapid cognitive decline, increased risk of abuse, and caregiver burden. This paper uses the Need-driven Dementia-compromised Behavior (NDB) model to explain aggression and discusses therapeutic approaches to care that combines non-pharmacological and pharmacological interventions targeting both the management of aggression crisis and preventing its future recurrence. A clinical algorithm guided by the NBD model is provided for practitioners.

Dietary intervention in older adults with early-stage Alzheimer dementia: early lessons learned

In older adults, an adequate diet depends on their ability to procure and prepare food and eat independently or the availability of dietary assistance when needed. Inadequate food intake or increased nutritional requirements lead to poor nutritional status, which is considered a key determinant of morbidity, increased risk of infection, and mortality in elderly individuals. Weight loss among seniors also heralds increased morbidity and mortality. Dietary behaviour disorders affecting food consumption, nutrition status and maintenance of body weight are common in older adults, and have a substantial impact on nutritional status and quality of life among older adults with Alzheimer Dementia (AD). The Nutrition Intervention Study (NIS) is ongoing. It employs a quasi-experimental pre-post intervention design in physically-well, community-dwelling early stage AD patients aged 70 y or older. To date, 34 intervention group patients and 25 control group participants have been recruited with their primary caregivers (CG) from 6 hospital-based memory and geriatric clinics in Montreal. The NIS uses clinical dietetics principles to develop and offer tailored dietary strategies to patients and their CG. This paper reports on the application of dietary intervention strategies in two intervention group participants; one was deemed successful while the other was considered unsuccessful. The report documents challenges encountered in assessing and counselling this clientele, and seeks to explain the outcome of intervention in these patients.

Association of body mass index with cognitive function in elderly hypertensive Japanese

BACKGROUND

As hypertension, obesity, and leanness are reported to be associated with poor cognitive function, it is possible that obesity or leanness in hypertensive patients may also be associated strongly with poor cognitive function.

METHODS

We recruited 184 elderly hypertensive patients comprising 93 very elderly (aged >or=80 years) and 91 younger elderly (aged 61-79 years) subjects. A mini-mental state examination (MMSE) and 24-h ambulatory blood pressure monitoring (ABPM) were performed in all participants. Patients were classified as either lean, normal physique, or obese according to the body mass index (BMI) quartile. The prevalence of poor cognitive function, total MMSE score, and MMSE subscores were compared between the groups.

RESULTS

The prevalence of poor cognitive function, total MMSE score, and MMSE subscore attention/calculation were significantly different between the groups both in the total study population and in the very elderly patients. The multiple logistic regression model showed that leanness was a significant determinant of poor cognitive function in both the total study population (odds ratio (OR) 2.54, 95% confidence interval (CI) 1.13-5.73, P = 0.02) and the very elderly patients (OR 3.94, 95% CI 1.31-11.82, P = 0.01). Obesity was not a significant determinant in either the total study population, very elderly, or younger elderly groups.

CONCLUSION

While obesity in hypertensive elderly patients was not associated with poor cognitive function, leanness in hypertensive elderly patients was, especially in the very elderly.

Influence of nutritional status on cognitive, functional and neuropsychiatric deficits in Alzheimer's disease

Nutrition is an important issue for elderly people, especially in patients with dementia. It is also related to clinical outcome, such as cognition, autonomy and behavior. The present study investigated the role of nutritional status on cognitive, functional and neuropsychiatric deficits in patients with Alzheimer's disease (AD). Forty-nine patients underwent neuropsychological, nutritional and neuropsychiatric assessments. The sample was divided into at risk of malnutrition (21 patients) and well-nourished (28 patients) according to the Mini Nutritional Assessment (MNA) score. The groups were similar for clinical and demographic variables, except for MNA score and age. The mean body mass index (BMI) was higher than the normal range. Patients at risk of malnutrition showed greater impairment, both in simple and instrumental activities of daily living (ADL and IADL) and a more severe ideomotor praxis deficit than well-nourished patients. Neuropsychiatric symptoms showed significant differences in hallucination, apathy, aberrant motor behavior and night-time subscales of Neuropsychiatric Inventory (NPI). These symptoms were more severe in patients at risk of malnutrition. Logistic regression analysis showed that malnutrition was an important risk factor for the onset of apathy. We hypothesized that changes in dietary habits and intake and the onset of these disorders reflect the involvement of a common neuroanatomical network.

Modeling behavioral and neuronal symptoms of Alzheimer's disease in mice: A role for intraneuronal amyloid

The amyloid Abeta-peptide (Abeta) is suspected to play a critical role in the cascade leading to AD as the pathogen that causes neuronal and synaptic dysfunction and, eventually, cell death. Therefore, it has been the subject of a huge number of clinical and basic research studies on this disease. Abeta is typically found aggregated in extracellular amyloid plaques that occur in specific brain regions enriched in nAChRs in Alzheimer's disease (AD) and Down syndrome (DS) brains. Advances in the genetics of its familiar and sporadic forms, together with those in gene transfer technology, have provided valuable animal models that complement the traditional cholinergic approaches, although modeling the neuronal and behavioral deficits of AD in these models has been challenging. More recently, emerging evidence indicates that intraneuronal accumulation of Abeta may also contribute to the cascade of neurodegenerative events and strongly suggest that it is an early, pathological biomarker for the onset of AD and associated cognitive and other behavioral deficits. The present review covers these studies in humans, in in vitro and in transgenic models, also providing more evidence that adult 3xTg-AD mice harboring PS1M146V, APPSwe, tauP301L transgenes, and mimicking many critical hallmarks of AD, show cognitive deficits and other behavioral alterations at ages when overt neuropathology is not yet observed, but when intraneuronal Abeta, synaptic and cholinergic deficits can already be described.

A randomized, crossover trial of high-carbohydrate foods in nursing home residents with Alzheimer's disease: associations among intervention response, body mass index, and behavioral and cognitive function

BACKGROUND

Despite recognition that weight loss is a problem in elderly persons with probable Alzheimer's disease (AD), increasing their food intake remains a challenge. To effectively enhance intake, interventions must work with individuals' changing needs and intake patterns. Previously, the authors reported greater food consumption at breakfast, a high-carbohydrate meal, compared with dinner, and shifts toward carbohydrate preference at dinner in those with increased behavioral difficulties, low body mass index, or both.

METHODS

Thirty-four nursing home residents with probable AD who ate independently participated in a randomized, crossover, nonblinded study of two nutrition interventions. The intervention described here included replacing 12 nonconsecutive "traditional" dinners with meals high in carbohydrate but comparable to traditional dinners in protein. Measures included weighed food intake, body weight, cognitive function (as assessed using the Severe Impairment Battery and Global Deterioration Scale), behavioral disturbances (as assessed using the Neuropsychiatric Inventory-Nursing Home Version), and behavioral function (as assessed using the London Psychogeriatric Rating Scale).

RESULTS

Group mean dinner and 24-hour energy intake increased during the intervention phase compared with baseline, protein intake was unaffected, and carbohydrate intake increased. Increased dinner intake, attributable to intervention foods, was achieved in 20 of 32 of participants who completed the study and was associated with increased carbohydrate preference, poorer memory, and increased aberrant motor behavior. Those with low body mass indices were the most resistant to the intervention.

CONCLUSIONS

Providing a high-carbohydrate meal for dinner increases food intake in seniors at later stages of the disease who are experiencing cognitive and behavioral difficulties, possibly as a result of a shift in preference for high-carbohydrate foods.