Longitudinal Trajectories of Awareness in Early-stage Dementia

Exploring longitudinal changes in implicit awareness of dementia: An investigation of the emotional Stroop effect in healthy ageing and mild dementia

The aim of the study was to investigate responses to dementia-relevant words in healthy older people and to investigate changes in response over 20-months in people with early-stage dementia. An emotional Stroop task, using colour-naming dementia-relevant words, was used as an indicator of implicit awareness of dementia. Overall, 24 people with dementia and 24 healthy older people completed an emotional Stroop task (T1). People with dementia completed the same task again after 12 (T2) and 20 (T3) months. For people with dementia emotional Stroop performance was contrasted with ratings of explicit awareness based on a detailed interview at T1 and at T2. For healthy older people and people with dementia response times to dementia-relevant words were significantly longer than those for neutral words. The effect was absent for people with dementia at T3. This decline in the emotional Stroop effect was not associated with cognitive decline as measured by the MMSE. Ratings of explicit awareness showed no significant change over time. There was no association between explicit awareness and implicit awareness. Implicit awareness of the condition is evident in early-stage dementia and can be elicited even where there is reduced explicit awareness. The emotional Stroop effect for dementia-relevant words in people with dementia appears to decline over time, independently of changes in MMSE score, suggesting that implicit awareness fades as time progresses.

Are you how you eat? Aspects of self-awareness in eating disorders

Eating disorders (ED) are severe psychiatric disorders characterized by dysfunctional behaviors related to eating or weight control, with profound impacts on health, quality of life, and the financial burden of affected individuals and society at large. Given that these disorders involve disturbances in self-perception, it is crucial to comprehend the role of self-awareness in their prevalence and maintenance. This literature review presents different self-awareness processes, discussing their functioning across different levels of complexity. By deconstructing this concept, we can gain a better understanding of how each facet of self and personality relates to the symptoms of these disorders. Understanding the absence or impairment of self-awareness in ED holds significant implications for diagnosis, treatment, and overall management. By recognizing and comprehending the characteristics of self-awareness, clinicians can develop tailored interventions and evidence-based treatments for individuals with ED. Furthermore, this narrative review underscores the importance of considering temperament and personality factors in the context of ED, as temperament traits and personality characteristics may interact with self-awareness processes, influencing the development and maintenance of ED. Ultimately, the results highlight the pressing need for further research on the development of effective interventions and support strategies grounded in the aspects of self-awareness mechanisms for individuals affected by these disorders.

Trajectories of cognitive and perceived functional decline in people with dementia: Findings from the IDEAL programme

INTRODUCTION

Impaired cognition and instrumental activities of daily living (iADL) are key diagnostic features of dementia; however, few studies have compared trajectories of cognition and iADL.

METHODS

Participants from the IDEAL study comprised 1537, 1183, and 851 people with dementia, and 1277, 977, and 749 caregivers at baseline, 12 and 24 months, respectively. Addenbrooke's Cognitive Examination-III and Functional Activities Questionnaire were used to measure cognition and iADL, respectively. Scores were converted to deciles.

RESULTS

Self-rated iADL declined on average by -0.08 (-0.25, 0.08) decile points per timepoint more than cognition. Informant-rated iADL declined on average by -0.31 (-0.43, -0.18) decile points per timepoint more than cognition.

DISCUSSION

Cognition and self-rated iADL declined at a similar rate. Informant-rated iADL declined at a significantly greater rate than cognition. Therefore, either cognition and perceived iADL decline at different rates or informants overestimate increasing iADL difficulties compared to both cognition and self-ratings.

HIGHLIGHTS

Self-ratings of the degree of functional difficulties were consistent with cognition Decline in self-rated everyday activities was consistent with cognitive decline Informant-ratings of everyday activities declined more than cognition.

Do we agree or disagree? A systematic review of the application of preference-based instruments in self and proxy reporting of quality of life in older people

PURPOSE

Quality of life is an important person-centred outcome in health and aged care settings. Due to an increasing prevalence of cognitive decline and dementia in ageing populations, a proportion of older people receiving health and aged care services may not be able to reliably assess their own quality of life, highlighting the need for proxy assessment. This systematic review sought to investigate the level of agreement between self and proxy-report of older people's quality of life using established preference-based instruments of quality of life suitable for economic evaluation.

METHODS

A systematic review was conducted following PRISMA guidelines. Eight databases were searched: Web of Science, Scopus, Medline, Econlit, PsychINFO, CINAHL, Ageline and Cochrane Library. Information was extracted on the instruments, population samples (including any cognitive thresholds applied), mean scores, type of proxy, and measures of inter-rater agreement.

RESULTS

A total of 50 studies using eight different preference-based quality of life instruments were identified. Most studies were cross-sectional (72%) with a wide variety of cognitive assessments and thresholds applied to define older participants with cognitive impairment. The most common proxies were family members, mostly spouses. The level of agreement between self and proxy-report was generally poor - irrespective of the instrument applied or type of proxy - with proxy-report generally indicating lower levels of quality of life than self-report. There was some evidence of stronger agreement on more observable quality of life domains e.g., physical health and mobility, relative to less observable domains e.g. emotional well-being. Few studies tracked self and/or proxy-report of quality of life longitudinally.

CONCLUSIONS

More research is needed to develop evidence to inform guidance on self-report versus proxy-report of quality of life for older people receiving health and aged care services. Until then, the collection of both self and proxy reports as complementary measures is indicated.

Longitudinal Trajectories of Quality of Life Among People With Mild-to-Moderate Dementia: A Latent Growth Model Approach With IDEAL Cohort Study Data

OBJECTIVES

We aimed to examine change over time in self-rated quality of life (QoL) in people with mild-to-moderate dementia and identify subgroups with distinct QoL trajectories.

METHODS

We used data from people with mild-to-moderate dementia followed up at 12 and 24 months in the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort study (baseline n = 1,537). A latent growth model approach examined mean change over time in QoL, assessed with the QoL-AD scale, and investigated associations of baseline demographic, cognitive, and psychological covariates with the intercept and slope of QoL. We employed growth mixture modeling to identify multiple growth trajectories.

RESULTS

Overall mean QoL scores were stable and no associations with change over time were observed. Four classes of QoL trajectories were identified: 2 with higher baseline QoL scores, labeled Stable (74.9%) and Declining (7.6%), and 2 with lower baseline QoL scores, labeled Stable Lower (13.7%) and Improving (3.8%). The Declining class had higher baseline levels of depression and loneliness, and lower levels of self-esteem and optimism, than the Stable class. The Stable Lower class was characterized by disadvantage related to social structure, poor physical health, functional disability, and low psychological well-being. The Improving class was similar to the Stable Lower class but had lower cognitive test scores.

DISCUSSION

Understanding individual trajectories can contribute to personalized care planning. Efforts to prevent decline in perceived QoL should primarily target psychological well-being. Efforts to improve QoL for those with poorer QoL should additionally address functional impairment, isolation, and disadvantage related to social structure.

Trajectories of socio-emotional functioning in early-stage dementia: implications for the individual with dementia and their family carer

BACKGROUND AND OBJECTIVES

Changes in socio-emotional functioning in people living with dementia (PLWD) are common; however, little is known about the broader effects these may have on wellbeing. This study examined socio-emotional functioning over time and associations with the wellbeing of PLWD and their family carers.

METHOD

One hundred and one individuals with a diagnosis of dementia and their respective carers completed the Social Emotional Questionnaire (assessing emotion recognition, empathy, social relationships and social behaviour) alongside measures of dementia severity, cognition, mood, stress, and relationship quality. Sixty-six dyads were reassessed on the same measures at 12 months post-baseline, and 51 dyads again at 20 months post-baseline.

RESULTS

When rated by the PLWD, there was no change in socio-emotional functioning over time; however, carers reported a significant decline over time. For both carers and the PLWD, poorer wellbeing measures were indicative of worse socio-emotional functioning at Time 1, though only dementia type, quality of life and relationship quality impacted upon the trajectory of socio-emotional decline over time.

CONCLUSIONS

Changes in social and emotional functioning are evident early in the course of dementia and worsen within 20 months. Both carer characteristics and those of the PWLD affected reporting of social and emotional functioning. These data are useful for guiding the provision of appropriate education and care.

Effects of dyadic discrepancy in awareness of mild cognitive impairment on changes in care partner's burden over time

Objectives:This study explored interpersonal aspects of coping with mild cognitive impairment (MCI), focusing on how shared illness representations between persons with MCI (PwMCI) and their care partners (CPs) are associated with CP perceived burden.Method:Longitudinal data from a purposive sample of 69 MCI care dyads were analyzed using descriptive statistics, t-tests, intraclass correlations, and regression analyses.Results: CP perceived their PwMCI's deficits in MCI-related functions as more negative than PwMCI rated themselves, but the extent of the discrepancy varied across cognitive and behavioral abilities. The discrepancy in dyadic appraisal of PwMCI functioning was associated significantly with CP burden.Conclusion: The findings highlight the value of shared PwMCI and CP perspectives on cognitive functioning for MCI management and psychological adjustment.

Changes in awareness of condition in people with mild-to-moderate dementia: Longitudinal findings from the IDEAL cohort

OBJECTIVES

Awareness of difficulties shown by people with dementia is known to vary, but few studies have explored changes in awareness over time. Investigating this could further the understanding of surrounding concepts and reasons for impaired awareness. Recognising emerging or diminishing awareness could facilitate discussions about diagnosis and appropriate post-diagnostic support.

METHODS

Using longitudinal data from the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort, awareness in community-dwelling people with mild-to-moderate dementia was assessed at three timepoints over 2 years. A validated checklist was used to evaluate awareness of difficulties associated with dementia. We examined changes in awareness for people with low awareness at baseline, and used case-matching to describe differences in characteristics between people who gained awareness, and those who continued with low awareness.

RESULTS

At baseline, 83 people from a sample of 917 showed low awareness. The majority of those remaining in the study at later timepoints had gained awareness, some as late as four or more years after diagnosis. Case-matched comparisons revealed few distinguishing characteristics: cases with stable low awareness had similar or better cognitive and functional ability than those who gained and retained awareness at 12 and 24 months, but may have had more co-morbidities.

CONCLUSIONS

Self-reported awareness of difficulties can change and may increase over time in people with mild-to-moderate dementia. There may be individual reasons for ongoing low awareness, not explained by cognitive or functional ability. This challenges the view that a single record of low awareness represents a fixed disease-related symptom, and highlights the complex, individual and dynamic nature of awareness.

Patients and physician’s self-assessment regarding clinical stability in severe mental disorders: a cross-sectional study

ABSTRACT Objective This study explores the relationship between patients’ self-assessment and physicians’ evaluation regarding clinical stability. Methods This cross-sectional study was carried out at the general outpatient clinic of the Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro (IPUB-UFRJ) in a large sample (1,447) of outpatients, of which 67.9% were patients with severe mental disorders (SMD). We collected information using a structured questionnaire developed for this purpose, filled in by the patient’s physician. Clinical stability was assessed by means of five psychiatric instability criteria and by the physician’s global clinical impression over the six previous months. The patients’ self-assessment was based on a question about how they evaluated their health status: stable/better, worse, does not know. For the analyses, patients’ self-evaluation was considered as our standard. Results The sample was composed of 824 (57%) women with an average age of 49 years. The most prevalent diagnoses within the SMD category corresponded to 937 patients, of whom 846 (90.3%) assessed themselves as stable/better. The physicians’ evaluations agreed more with patients with bipolar disorders and less with schizophrenics regarding stability. As for patients with depressive disorder, physicians agreed more with them regarding instability. Conclusion The data analysis confirms our hypothesis that the self-assessment made by patients with SMD was accurate regarding their health condition, and that the self-assessment made by patients who considered themselves stable agree with the physicians’ evaluation.

The Relationship Between Decision-making Capacity and the Domains of Awareness in Alzheimer Disease

People with Alzheimer dementia (PwAD) who are aware of their overall cognitive function and diagnosis are more likely to be judged competent in decision-making capacity. Therefore, we aimed to investigate the relationship between decision-making capacity and the different domains of awareness and the relationship between decision-making capacity and the cognitive and clinical impairment of the PwAD. Using a cross-sectional design, we included 121 PwAD and their caregivers. Awareness was assessed across domains, including cognitive functioning and health condition, functional activity impairments, emotional state, social functioning, and interpersonal relationships. The MacArthur Competence Assessment Tool for Treatment was adopted to gather information about decision-making abilities. We found that decision-making capacity is related to the cognitive and functional domains of awareness and relatively independent of the emotional functioning and the relationship domains. Our finding highlighted that PwAD who are unaware of the disease or the cognitive and functional impairments might be unlikely to appreciate the personal benefits of a proposed health treatment or to understand and judge the personal consequences of a decision accurately.

Subjective cognitive decline: opposite links to neurodegeneration across the Alzheimer's continuum

Subjective memory decline is associated with neurodegeneration and increased risk of cognitive decline in participants with no or subjective cognitive impairment, while in patients with mild cognitive impairment or Alzheimer's-type dementia, findings are inconsistent. Our aim was to provide a comprehensive overview of subjective memory decline changes, relative to objective memory performances, and of their relationships with neurodegeneration, across the clinical continuum of Alzheimer's disease. Two hundred participants from the Imagerie Multimodale de la maladie d'Alzheimer à un stade Précoce (IMAP+) primary cohort and 731 participants from the Alzheimer's Disease Neuroimaging Initiative (ADNI) replication cohort were included. They were divided into four clinical groups (Imagerie Multimodale de la maladie d'Alzheimer à un stade Précoce/Alzheimer's Disease Neuroimaging Initiative): controls (n = 67/147, age: 60-84/60-90, female: 54/55%), patients with subjective cognitive decline (n = 30/84, age: 54-84/65-80, female: 44/63%), mild cognitive impairment (n = 50/369, age: 58-86/55-88, female: 45/44%) or Alzheimer's-type dementia (n = 36/121, age: 51-86/61-90, female: 41/41%). Subjective and objective memory scores, and their difference (i.e. delta score reflecting memory awareness), were compared between groups. Then, voxelwise relationships between subjective memory decline and neuroimaging measures of neurodegeneration [atrophy (T1-MRI) and hypometabolism (¹⁸F-fluorodeoxyglucose-PET)] were assessed across clinical groups and the interactive effect of the level of cognitive impairment within the entire sample was assessed. Analyses were adjusted for age, sex and education, and repeated including only the amyloid-positive participants. In Imagerie Multimodale de la maladie d'Alzheimer à un stade Précoce, the level of subjective memory decline was higher in all patient groups (all P < 0.001) relative to controls, but similar between patient groups. In contrast, objective memory deficits progressively worsened from the subjective cognitive decline to the dementia group (all P < 0.001). Accordingly, the delta score showed a progressive decline in memory awareness across clinical groups (all P < 0.001). Voxelwise analyses revealed opposite relationships between the subjective memory decline score and neurodegeneration across the clinical continuum. In the earliest stages (i.e. patients with subjective cognitive decline or Mini Mental State Examination > 28), greater subjective memory decline was associated with increased neurodegeneration, while in later stages (i.e. patients with mild cognitive impairment, dementia or Mini Mental State Examination < 27) a lower score was related to more neurodegeneration. Similar findings were recovered in the Alzheimer's Disease Neuroimaging Initiative replication cohort, with slight differences according to the clinical group, and in the amyloid-positive subsamples. Altogether, our findings suggest that the subjective memory decline score should be interpreted differently from normal cognition to dementia. Higher scores might reflect greater neurodegeneration in earliest stages, while in more advanced stages lower scores might reflect decreased memory awareness, i.e. more anosognosia associated with advanced neurodegeneration.

Does awareness of condition help people with mild-to-moderate dementia to live well? Findings from the IDEAL programme

Background

People living with dementia vary in awareness of their abilities. We explored awareness of the condition and diagnosis in people with mild-to-moderate dementia, and how this relates to quality of life, well-being, life satisfaction, and caregiver stress.

Methods

This study was a cross-sectional exploratory analysis of data from the IDEAL cohort, which recruited people with dementia living at home and available caregivers from 29 research sites in Great Britain. Our study included 917 people with mild-to-moderate dementia and 755 carers. Low and high awareness groups were derived from self-reported responses to a dementia representation measure. Logistic regression was used to explore predictors of awareness of condition and diagnosis using demographic, cognitive, functional and psychological measures, and the relationship with quality of life, well-being and life satisfaction (‘living well’), and caregiver stress.

Results

There were 83 people with low awareness of their condition. The remaining 834 people showed some awareness and 103 of these had high awareness of their condition and diagnosis. Psychosocial factors were stronger predictors of awareness than cognitive and functional ability. Those with higher awareness reported lower mood, and lower scores on indices of living well as well as lower optimism, self-efficacy and self-esteem. Low awareness was more likely in those aged 80y and above, and living in more socially deprived areas. No relationship was seen between caregiver stress and awareness.

Conclusions

Awareness of the condition and diagnosis varies in people with mild-to-moderate dementia and is relevant to the capability to live well. Awareness should be considered in person-centered clinical care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02468-4.

Patient-Reported Outcome Measures to Inform Care of People With Dementia-A Systematic Scoping Review

BACKGROUND AND OBJECTIVES

Patient-reported outcome measures (PROMs) captures the patient's perspective regarding quality of life, daily functioning, symptom severity, and overall health, and how these may be impacted by health care or other interventions. PROMs are used in clinical quality registries (CQRs) for a number of diseases to assess the patient's perspective of the impact of clinical care on quality-of-life. This scoping review aimed to identify dementia-specific PROMs, determine how the PROMs are being used, and whether they are used within dementia registries.

RESEARCH DESIGN AND METHODS

Three electronic databases were searched using Medical Subject Heading terms for dementia, quality of life, and patient-reported outcomes. Data were extracted on the PROMs used and the methods and mode of administering the PROM.

RESULTS

Seven dementia-specific PROMs were identified, however none were used in a dementia registry. All the PROMs were used at the patient level to identify patient needs and health service impacts. Three PROMs were also used at a system level to examine difference in care models. The majority of the PROMs were administered via a researcher or clinician and were predominantly completed by a proxy.

DISCUSSION AND IMPLICATIONS

PROMs provide an opportunity for a patient with dementia to share experiences and perspectives of care. A number of dementia-specific PROMs exist, yet none are used in dementia registries and the majority of studies utilize PROMs via a proxy. The use of PROM for patients with dementia, particularly in the context of dementia registries, requires further exploration and consideration.

Domains of awareness in Alzheimer's disease: The influence of executive function

OBJECTIVE

Awareness is a developing area in dementia research and the evaluation of its domains has been increasingly included as part of care for people with Alzheimer's disease (PwAD). Our aim is to examine whether executive dysfunction is associated with awareness domains.

METHODS

A consecutive series of 75 people with mild-to-moderate Alzheimer's disease completed assessments about global cognitive function, executive functioning, and their awareness of disease. Their primary caregivers' dyad provided information about demographics, awareness of disease, dementia severity, neuropsychiatric symptoms, and functional status.

RESULTS

Different types of executive dysfunction were presented as a predictor for awareness of disease (cognitive flexibility, inhibitory control, and working memory), of emotional state (short-term memory and attention) and of social functioning and relationships (visuospatial organization, integrative functions, and abstract thinking). Awareness of cognitive functioning and health condition and of functional activity impairments exhibit only global cognitive function as a predictor.

CONCLUSIONS

Findings confirm some degree of independence between awareness domains. The importance of identifying differences in domains of awareness relies in the understanding of awareness as a clinical phenomenon in order to guide the management and support of PwAD and their caregivers.

Anosognosia in dementia with Lewy bodies: a systematic review

BACKGROUND

Anosognosia, i.e. lack of awareness of one's own symptoms, is a very common finding in patients with dementia and is related to neuropsychiatric symptoms and worse prognosis. Although dementia with Lewy bodies (DLB) is the second most common form of degenerative dementia, literature on anosognosia in this disease is scarce.

OBJECTIVES

This paper aimed to review the current evidence on anosognosia in patients with DLB, including its prevalence in comparison with other neurological conditions, its severity and anatomical correlations.

METHODS

Database searches were performed in PubMed, Web of Knowledge and PsycINFO for articles assessing anosognosia in DLB. A total of 243 studies were retrieved, but only six were included in the review.

RESULTS

Potential risk of selection, comparison or outcome biases were detected in relation to all the studies selected. Most of the studies used self-report memory questionnaires to assess cognitive complaints and compared their results to scores from informant-based instruments or to participants' cognitive performance in neuropsychological tasks. Subjects with DLB had worse awareness regarding memory than healthy older controls, but the results concerning differences in anosognosia between DLB and Alzheimer's disease (AD) patients were inconsistent across studies. Presence of AD pathology and neuroimaging biomarkers appeared to increase the prevalence of anosognosia in individuals with DLB.

CONCLUSION

Anosognosia is a common manifestation of DLB, but it is not clear how its prevalence and severity compare with AD. Co-existence of AD pathology seems to play a role in memory deficit awareness in DLB.

Awareness of Functional Status: People with Alzheimer's Disease Abilities to Self-Report Impairment in Activities of Daily Living

BACKGROUND

Awareness of functional status may underlie specific profiles and differences related to stage severity in individuals with Alzheimer's disease (AD).

OBJECTIVE

This study aimed to assess self-reported experiences of awareness of functional activity in people with mild and moderate AD.

METHODS

This is a mixed methods approach. The qualitative part was conducted through semi-structured interviews concerning the experiences and awareness of deficits in 38 older adults with mild or moderate AD. The quantitative approach included a comparison between groups with regard to concerns of awareness and clinic and demographic data.

RESULTS

Impairment on awareness of disease and awareness of functional deficits was observed even in the mild stages of AD. There was also a noticeable progression of impairments of both kinds of awareness from mild to moderate stage of disease. The majority of participants with mild and moderate AD were partially aware of their functional deficits. Both groups of participants reported some negative impact; however, they were not able to entirely describe their functional status. Also, deficits to recognize the need for help with hygiene and general tasks were observed. Significant differences were found in awareness of need for help with general tasks and awareness of need for help with hygiene tasks.

CONCLUSION

People with mild and moderate AD may describe their aware of the disease better than specific functional deficits, and most of them can provide some reports concerning to the impact of the disease.

Dementia Cafés as Hubs to Promote Community-Integrated Care for Dementia through Enhancement of the Competence of Citizen Volunteer Staff Using a New Assessment Tool

INTRODUCTION

Dementia cafés have recently been attracting attention. The increased involvement of citizen volunteers and the competence of dementia café staff could enhance the potential of dementia cafés. The aim of the present study was to examine enhancement of the competence of citizen volunteers using a new assessment tool.

METHODS

This cross-sectional analysis included 433 dementia café staff members, including medical and care professionals and citizen volunteers. A 20-item dementia café staff self-assessment (DCSA) instrument was newly developed. After confirmation of the reliability and validity of the instrument, DCSA scores among citizen volunteers were evaluated.

RESULTS

DCSA showed very good psychometric properties. The mean (±SD) DCSA score was significantly higher for café staff with a medical and care professional background (n = 267) than for citizen volunteers (n = 166) (2.2±0.5 vs. 1.7±0.7, respectively; p < 0.001). The DCSA scores of citizen volunteers became significantly higher with increasing attendance (minimum: n = 24; 1.3±0.7; intermediate: n = 65; 1.6±0.6; and frequent: n = 77; 1.8±0.7; p < 0.01).

CONCLUSION

Assessment of the competence of dementia café staff using the DCSA revealed the potential of citizen volunteers. This tool could also enhance the potential of dementia cafés.

The power of the Functional Activities Questionnaire for screening dementia in rural-dwelling older adults at high-risk of cognitive impairment

AIM

A simple approach to detecting dementia in its early stages may help improve patient care. We therefore aimed to assess the power of the Functional Activities Questionnaire (FAQ) for screening dementia among rural-dwelling older adults who are at high-risk for cognitive impairment.

METHODS

This study included 961 participants at a high-risk for dementia who had been identified from a population-based survey of Chinese rural residents. All participants were aged 65 years and older and positive for cognitive impairment according to the Mini-Mental State Examination or the Ascertain Dementia 8-item Informant Questionnaire screening tests. The FAQ scale was used to evaluate daily activities. Dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria. Receiver operating characteristic curve analyses were used to determine the FAQ's optimal cut-offs for dementia. The power (or accuracy) of the FAQ for screening dementia was analyzed in the total sample and in subgroups categorized by age, gender, and educational level.

RESULTS

Of the 961 participants, 84 (8.7%) were clinically diagnosed with dementia. Among individuals who were positive for cognitive impairment on the Mini-Mental State Examination or the Ascertain Dementia 8-item Informant Questionnaire, the parameters for an FAQ cut-off score ≥6 as a means of discriminating those with dementia from those without dementia were area under curve = 0.899, sensitivity = 94.1%, specificity = 75.1%, positive likelihood ratio = 3.78, and accuracy = 0.768. The discriminant abilities of the FAQ scale varied with age, gender, and educational level. The discriminant parameters of the FAQ scale were similar overall among individuals who were positive on either the Mini-Mental State Examination or the Ascertain Dementia 8-item Informant Questionnaire test alone.

CONCLUSION

The FAQ scale has high discriminative power to screen for dementia among rural older residents with suspected cognitive impairment.

Comparison of mortality rate in older adults with and without functional awareness: the Neurological Disorders in Central Spain (NEDICES) population-based study

OBJECTIVES

The main aim of the study was to compare the rates of mortality in older adults with and without functional unawareness (FU). We also tested a possible interaction effect between levels of awareness and education, as a single cognitive reserve proxy, on mortality.

STUDY DESIGN

The study design is a longitudinal population-based cohort study.

METHODS

The Neurological Disorders in Central Spain is epidemiological study to detect main age-associated conditions in people aged 65 years and older. Participants were collected from updated population-based registers of residents in three areas of central Spain. Awareness of functional limitations was established in accordance with the discrepancy between two sources of information on functional impairments: reliable informants versus the participants themselves. Three mutually exclusive groups were formed, namely, Functional Limitation Complaints (FCs), FU, and Functional Awareness (FA). Cox's regression models, adjusted by different covariates, were used to calculate the risk of mortality for each group at 5-year follow-up (vs. reference group without limitations).

RESULTS

Of 1818 selected individuals, 229 (12.5%) showed FA, 254 (13.9%) showed FC, and 96 (5%) were classified as FU. All these groups showed an increased risk of mortality at 5-year follow-up [adjusted hazard ratio (HR) for FC < FU < FA]. However, the association of FU with mortality remained significant only for highly educated individuals.

CONCLUSIONS

Functional impairment was associated with increased mortality rates, regardless of the presence of unawareness. This study extends the role of education in modulating the symptoms and prognosis of individuals at very mild or preclinical dementia stages.

Patterns of discrepancies in different objects of awareness in mild and moderate Alzheimer's disease

Objectives: Awareness is considered a heterogeneous and non-linear phenomenon in dementia. We aim to investigate patterns of change of different domains of awareness (awareness of cognitive functioning and health condition, activities of daily living, emotional state, social functioning, and relationships) in people with mild and moderate Alzheimer's disease (AD) and aspects related to each domain.Method: Cross-sectional assessment of dyads of people with AD (PwAD) and caregivers (n = 128; CDR1 = 74, CDR2 = 54). PwAD completed assessments about quality of life, cognition and their awareness of disease. Caregivers provided information about PwAD and received quality of life and burden of care assessments.Results: Mild AD group showed a mildly impaired awareness (n = 40; 54.05%), while moderate AD group, showed higher presence of moderately impaired awareness (n = 22; 40.74%). There was a significant difference between groups in awareness of cognitive functioning and health condition (p < 0.004), functional activity impairments (p < 0.001) and total score of awareness (p < 0.01). Conversely, awareness of emotional state (p = 0.22) and of social functioning and relationship (p = 0.44) presented no significant difference between groups. Unawareness of functional activity impairments showed higher discrepancy scores between PwAD and caregivers in both groups.Conclusions: Significant differences were found only in patterns of discrepancies in awareness of cognitive functioning and health condition, of ADL and socio-emotional functioning. Different factors are related to different domains in mild and moderate group, reinforcing the heterogeneity of awareness in dementia. ADL deficits have an important role in awareness phenomenon, independent of the severity of disease.

Future outlook of people living alone with early-stage dementia and their non-resident relatives and friends who support them

Little is known about the experiences of people living alone with dementia in the community and their non-resident relatives and friends who support them. In this paper, we explore their respective attitudes and approaches to the future, particularly regarding the future care and living arrangements of those living with dementia. The study is based on a qualitative secondary analysis of interviews with 24 people living alone with early-stage dementia in North Wales, United Kingdom, and one of their relatives or friends who supported them. All but four of the dyads were interviewed twice over 12 months (a total of 88 interviews). In the analysis, it was observed that several people with dementia expressed the desire to continue living at home for ‘as long as possible’. A framework approach was used to investigate this theme in more depth, drawing on concepts from the existing studies of people living with dementia and across disciplines. Similarities and differences in the future outlook and temporal orientation of the participants were identified. The results support previous research suggesting that the future outlook of people living with early-stage dementia can be interpreted in part as a response to their situation and a way of coping with the threats that it is perceived to present, and not just an impaired view of time. Priorities for future research are highlighted in the discussion.

A Systematic Review of Multimodal Non-Pharmacological Interventions for Cognitive Function in Older People with Dementia in Nursing Homes

INTRODUCTION

Multimodal non-pharmacological interventions (MNPIs) have been reported to be effective in improving the cognitive function. Therefore, it is necessary to study these interventions in older people with dementia (PWD) in nursing homes (NHs).

AIMS

This study aimed to investigate the effects, contents, frequency, duration, length, and form of MNPIs on the global and specific cognitive functions of PWD in NHs through a systematic review, and to consider what kind of intervention design is most effective.

METHODS

A systematic search of peer-reviewed literature published between January 2008 and October 2018 was performed on the PubMed, Cochrane Library, Web of Science and CINAHL databases.

RESULTS

Six randomized controlled trials (RCTs) and one non-RCTs were extracted from electronic databases, and a review was carried out.

CONCLUSION

Our review suggests that MNPIs may improve the global, executive function and memory of PWD in NHs. The combination of exercise, cognitive training and activities of daily living, and intervention at least 3 times a week over at least 8 weeks with, at least 30 min per session using the integrated form is recommended for improving the global and specific cognitive functions of PWD in NHs.

Evolution of anosognosia in alzheimer's disease and its relationship to amyloid

OBJECTIVE

Unawareness, or anosognosia, of memory deficits is a challenging manifestation of Alzheimer's disease (AD) that adversely affects a patient's safety and decision-making. However, there is a lack of consensus regarding the presence, as well as the evolution, of altered awareness of memory function across the preclinical and prodromal stages of AD. Here, we aimed to characterize change in awareness of memory abilities and its relationship to beta-amyloid (Aβ) burden in a large cohort (N = 1,070) of individuals across the disease spectrum.

METHODS

Memory awareness was longitudinally assessed (average number of visits = 4.3) and operationalized using the discrepancy between mean participant and partner report on the Everyday Cognition scale (memory domain). Aβ deposition was measured at baseline using [18F]florbetapir positron emission tomographic imaging.

RESULTS

Aβ predicted longitudinal changes in memory awareness, such that awareness decreased faster in participants with increased Aβ burden. Aβ and clinical group interacted to predict change in memory awareness, demonstrating the strongest effect in dementia participants, but could also be found in the cognitively normal (CN) participants. In a subset of CN participants who progressed to mild cognitive impairment (MCI), heightened memory awareness was observed up to 1.6 years before MCI diagnosis, with memory awareness declining until the time of progression to MCI (-0.08 discrepant-points/yr). In a subset of MCI participants who progressed to dementia, awareness was low initially and continued to decline (-0.23 discrepant-points/yr), reaching anosognosia 3.2 years before dementia onset.

INTERPRETATION

Aβ burden is associated with a progressive decrease in self-awareness of memory deficits, reaching anosognosia approximately 3 years before dementia diagnosis. ANN NEUROL 2020;87:267-280.

"What would you like to achieve?" Goal-Setting in Patients with Dementia in Geriatric Rehabilitation

BACKGROUND

Setting meaningful, individualized rehabilitation goals is an essential part of the rehabilitation process. Even though patients with dementia are a drastically increasing patient group in geriatric rehabilitation, empirical data about meaningful rehabilitation goals and collaborative goal-setting in this target group is missing. Cognitive impairment and lack of insight in current deficits have been discussed as barriers for participation in goal-setting, but require empirical examination. This study investigated the feasibility of a semi-structured versus a structured goal-setting approach and the types of goals, rehabilitation patients with mild to moderate dementia perceive as personally relevant. Insights in acute functional and motor deficits, differentiated by cognitive status were explored.

METHODS

Cohort study in a geriatric rehabilitation center. Semi-structured and ICF-based, structured interviews were applied to explore patients` rehabilitation goals. Patients` insight in deficits was operationalized as the relationship of self-ratings and objective measures of linked clinical assessments for the same functional construct.

RESULTS

Patients (n = 101, MMSE 22 ± 2.6, age 83.9 ± 5.9 years) stated the improvement of mobility-related functions and self-care activities (> 70%) but also psychological well-being such as handling stress or mood (> 38%) as most important rehabilitation goals. The structured interview facilitated goal-setting and provided a broader view of rehabilitation needs. Correlations between self-ratings and clinical assessments were medium to high (rho = 0.29 to 0.83) with highest associations for key motor features. Trend tests identified a significant trend between values of the clinical assessment and categories of self-ratings (p ≤ 0.01) with lower cognitive status derogating this relationship.

CONCLUSIONS

Collaborative goal-setting was feasible, especially when supported by a structured approach and yielded a large spectrum of functional but also psychological rehabilitation needs from the patients` perspective. Patients showed sustained insight in their actual functional impairments, limited in a subgroup of patients with more advanced cognitive impairment.

Relationships between Cognition and Activities of Daily Living in Alzheimer's Disease During a 5-Year Follow-Up: ALSOVA Study

BACKGROUND

Impaired cognition and activities of daily living (ADL) are core symptoms of Alzheimer's disease (AD), but their relationship is unclear.

OBJECTIVES

To explore relationships between cognitive domains and functional ability during 5-year follow-up in persons with AD.

METHODS

We analyzed ALSOVA study data from 236 individuals with very mild or mild AD at baseline. The CERAD Neuropsychological Battery (CERAD-NB) was used as a cognitive measure and Alzheimer's Disease Cooperative Study ADL (ADCS-ADL) as a functional measure, analyzing the IADL and BADL sub-scores separately. Annual regression models and linear mixed-effect models (LMMs) covering a 5-year follow-up period were used.

RESULTS

Annually, the CERAD-NB total and especially Verbal Fluency, Clock Drawing, and Constructional Praxis were associated with the total ADCS-ADL and IADL scores increasingly yet modestly, and to a lesser extent the BADL score. In the LMMs, the same measures and MMSE were associated with ADL.

CONCLUSION

Measures of executive function and visuoconstructive skills appear to be associated with caregiver-interview based ADL measure during the progression of AD.

Interaction between memory impairment and depressive symptoms can exacerbate anosognosia: a comparison of Alzheimer's disease with mild cognitive impairment

OBJECTIVE

To investigate the effects of interactions between memory impairment, depressive symptoms, and anosognosia.

METHODS

Anosognosia for memory impairment was assessed in 118 patients with Alzheimer's disease (AD), 47 patients with mild cognitive impairment (MCI), and 17 non-diagnosed controls (NC) using a questionnaire and evaluation of the anosognosia score as the discrepancy between ratings of the patient and a relative. Demographic characteristics, such as the relationship of the patient with the relative and the activities of daily living (ADL) were evaluated. Memory impairment was evaluated with the Rivermead Behavioral Memory Test (RBMT), depressive symptoms were evaluated using the Geriatric Depression Scale (GDS) 15 items version.

RESULTS

In the MCI group, a stepwise multiple regression analysis showed an interaction between RBMT and GDS scores, and simple slope analysis indicated that scores for RBMT at low GDS (-1 standard deviation) were positively correlated with self-rated memory impairment. In the AD group, the relationship of the patient with the relative, ADL, and GDS and RBMT scores were associated with the anosognosia score.

CONCLUSION

Patients with MCI who have no depressive symptoms may be able to more accurately evaluate their memory impairment than those who have depressive symptoms and patients with AD. The evaluation by relatives, depressive symptoms or ADL of patients may distort evaluation of anosognosia for memory impairment in patients with AD or MCI. It seems necessary to include not only depression scale scores but also results of objective memory tests in the patients' medical information for the correct assessment of anosognosia.

Awareness in Dementia: Development and Evaluation of a Short Version of the Assessment Scale of Psychosocial Impact of the Diagnosis of Dementia (ASPIDD-s) in Brazil

Awareness of disease is defined as the recognition of changes caused by the deficits related to the disease process. We aimed to examine the psychometric properties of the short versions of the Assessment Scale of Psychosocial Impact of the Diagnosis of Dementia (ASPIDD-s), a multidimensional awareness scale. Using a cross-sectional design, we included 201 people with dementia and their family caregivers. The creation of the short versions was based on items with higher loadings on each factor, the correlations between the short versions and demographic or clinical variables and the relevance of the item to the respondent population. Three short versions were created: version 1 and 3, with 12 items and version 2, with 16 items. The short versions correlated very strongly with the full scale and with the 4 factors of the original scale, maintaining the multidimensional nature of the ASPIDD. Loss of awareness was associated with worse quality of life, decreased functionality and cognitive level, and higher caregiver burden across the short versions. Considering the appropriateness of the items and their clinical relevance, we recommend version 3 for use. With only 12 items, the time required for the completion of the scale is short, while maintaining robust psychometric properties.

Antecedents and consequences of unawareness of memory impairment in dementia

OBJECTIVE

To assess the prevalence, antecedents, and consequences of unawareness of memory impairment in dementia.

METHOD

Persons (n = 1,862) from a geographically defined community without dementia at enrollment subsequently underwent clinical classification (248 with dementia, 611 with mild cognitive impairment, 1,003 with no cognitive impairment), memory testing, and self-appraisal of memory. Memory performance was regressed on self-appraised memory, and the residuals served as an index of memory awareness. After clinical classification, participants completed brief cognitive testing at 3-year intervals for up to 15 years.

RESULTS

When unawareness was defined as a score at or below thresholds ranging from the 15th to 25th percentiles, it was more common in dementia (67%-83%) and mild cognitive impairment (15%-33%) than in no cognitive impairment (2%-6%; all p < .001). A continuous measure of awareness (M = 0.00, SD = 0.61) was reduced by 0.37-unit in mild cognitive impairment (SE = 0.04, p < .001) and 1.04-unit in dementia (SE = 0.06), p < .001) compared with those without cognitive impairment, and these associations were weaker in Black persons than White persons (estimate for dementia by race = 0.37, SE = 0.12, p = .003; estimate for mild cognitive impairment by race = 0.30, SE = 0.08, p < .001). Higher premorbid neuroticism was associated with better memory awareness in dementia. Higher memory awareness was not related to mortality in mild cognitive impairment or dementia but had a marginal association with slower cognitive decline in mild cognitive impairment.

CONCLUSIONS

Unawareness of memory impairment is a common manifestation of dementia, particularly in White persons, but is not strongly related to adverse disease outcomes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Needs and quality of life of people with middle-stage dementia and their family carers from the European Actifcare study. When informal care alone may not suffice

OBJECTIVE

The Actifcare (Access to timely formal care) study investigated needs of people with dementia and their families during the phase in which formal care is being considered, and examined whether higher need levels are related to lower quality of life (QOL).

METHOD

From eight European countries 451 people with dementia and their carers participated. Needs were measured with the Camberwell Assessment of Need for the Elderly. QOL was measured with the QOL-AD, and carer quality of life was measured with the CarerQol. The relationship between needs and QOL was analysed with multiple regression analyses.

RESULTS

Needs were expressed in the domains of psychological distress, daytime activities, company and information. People with dementia rated their unmet needs significantly lower than their carers: the mean number of self-rated unmet needs was 0.95, whereas the mean proxy ratings were 1.66. For met needs, the self-rated mean was 5.5 and was 8 when proxy-rated. The level of needs reported was negatively associated with QOL for both.

CONCLUSION

The study results show that informal carers reported almost twice as many needs as people with dementia. The domains in which needs are expressed should be the primary focus for interventions to support   QOL. The perspectives of people with dementia are informative when identifying needs.

Beliefs About Dementia: Development and Validation of the Representations and Adjustment to Dementia Index (RADIX)

OBJECTIVES

The Self-Regulation Model (SRM) identifies that the beliefs people hold about an illness can influence their responses to that illness. Although there are generic measures of illness representations, there is a need for a brief tailored measure to use with people with dementia. The aim of this study was to develop and validate a brief measure called the Representations and Adjustment to Dementia Index (RADIX). The RADIX contains questions on the SRM elements: Identity, Cause, Timeline, Control, and Consequences.

METHODS

The RADIX validation was conducted with a sample of 385 community-dwelling people with mild to moderate dementia who were taking part in the IDEAL cohort study. Test-retest reliability was conducted over a 4-week period with a separate sample of 20 people with dementia.

RESULTS

The validation process resulted in a reduction in the number of items in the Timeline, Control, and Consequences items. The resulting RADIX demonstrated good acceptability, internal reliability, and test-retest reliability. All the RADIX items had low missing data, indicating good acceptability. The factor analysis confirmed that the Consequences items formed two subscales (practical and emotional consequences) that had Cronbach's α of 8 and 0.91 respectively. Test-retest reliability indicated that the Identity, Timeline, and Control items had moderate reliability and the practical and emotional consequences scales had good reliability.

CONCLUSIONS

The RADIX demonstrates acceptable psychometric properties, proves to be a useful measure for exploring people's beliefs about dementia, and could aid the provision of tailored information and support to people with dementia.

The Proactive Self in Space: How Egocentric and Allocentric Spatial Impairments Contribute to Anosognosia in Alzheimer's Disease

In addition to impairments in episodic and spatial memory, anosognosia (i.e., loss of awareness of the deficient aspect of own cognitive functioning) may be considered an important cognitive marker of Alzheimer's disease (AD). However, although a growing body of interesting models have been proposed to explain this early symptom, what is still missing is a unifying framework of all the characteristic signs occurring in patients with AD that may guide the search for its causal neuropathological process and, ultimately, the etiological process. This contribution will first show how anosognosia may be related to the above-mentioned episodic and spatial memory impairment through a unifying framework of all these characteristic signs, i.e., the continuous interaction between different spatial representations. Second, we hypothesize that a break in the interaction between different spatial representations, as we suggest occurs in AD, may contribute significantly both to the early impairments in spatial and episodic memory, and to a deficient self-awareness since it may interfere with the capacity of the brain to detect predictive errors.

The Relationship Between Social Cognition and Awareness in Alzheimer Disease

A large body of evidence highlights the social cognitive impairment in neurodegenerative diseases such Alzheimer disease (AD). This study investigated the relationship among social and emotional functioning (SEF), awareness of disease, and other clinical aspects in people with AD (PwAD). A consecutive series of 50 people with mild to moderate AD and their 50 family caregivers were assessed. There was a significant difference between self-rated SEF and informant-rated SEF. In 56% of PwAD, self-rated SEF is lower than informant-rated SEF. People with AD mostly presented with mildly impaired awareness of the disease (56%), 20% had moderately impaired awareness of the disease, and 6% were unaware of the disease. The multivariate linear regression showed that informant-rated SEF was related to the social functioning, and relationships, domains of awareness of disease, and the PwAD informant-rated quality of life. The relationship between SEF and awareness of social functioning and relationship domain shows that they are comprised of judgments related to perceptions about oneself, values, and beliefs qualitatively different from awareness of memory or functionality, which can be directly observed.

Awareness of functional ability in people with early-stage dementia

OBJECTIVES

Assessment of functional ability in people with early-stage dementia (PwD) is an important area of study because it forms part of the diagnostic process and may help in monitoring disease progression. Most researchers and clinicians rely on informant ratings rather than observing actual functional performance or employing self-ratings. There has however been little research to verify whether informant ratings of functioning are accurate, and there has been even less research investigating the accuracy of self-ratings of functional ability in PwD. No study has used the performance-monitoring metacognitive approach to investigate awareness of functional ability.

METHODS

Thirty-seven people with early-stage dementia completed an objective functional assessment and provided self-ratings before and after completing each section of the objective test. Informants provided ratings of functioning and burden. Scores were converted to percentages to allow for direct comparison.

RESULTS

Objectively assessed functional ability significantly correlated with self-ratings and informant ratings. Self-ratings did not correlate with informant ratings. For converted scores, self-ratings were more similar than informant ratings to the objectively assessed mean scores. Burden was unrelated to functional assessments after correcting for multiple comparisons.

CONCLUSIONS

Self-rated functional ability was more accurate than informant ratings when compared with objectively assessed ability, with informants tending to significantly underestimate the functional ability of PwD. The findings call into question the likelihood that informants will provide accurate ratings of functional ability and suggests that self-ratings may offer a more accurate estimate of functional ability. Self-ratings made by PwD should be more widely employed in clinical and research settings. Copyright © 2017 John Wiley & Sons, Ltd.

Integrating the Constructs of Anosognosia and Metacognition: a Review of Recent Findings in Dementia

The current review integrates recent findings regarding the construct of self-awareness in dementia from both clinical and cognitive perspectives. We present the predominant theoretical models of awareness and summarize both traditional and emerging approaches to assessing awareness from clinical and meta-cognitive perspectives. In this review, we focus primarily on findings from recent studies in anosognosia and meta-cognition in the context of neurodegenerative disease with special emphasis on Alzheimer's disease and frontotemporal dementia. Emerging trends in the study of awareness, including examination of the longitudinal course of anosognosia, and investigation of the neural substrates underlying meta-cognitive abilities are addressed. Finally, the practical importance of studying and assessing awareness from both theoretical and clinical angles is emphasized.

Perceptions of stigma among people affected by early- and late-onset Alzheimer's disease

 = 14). Perceived stigma reporting was low in the questionnaires, whereas interviews revealed higher levels of perceived stigma in the form of unpredictable reactions to diagnosis, feeling stupid and ignorance of the condition among the public. Perceived stigma was managed in similar ways across age groups, focusing on 'being the lucky ones'. Results support the need to further tackle stigma and challenge expectations, particularly given the drive to diagnose people and thereby expose them to stigma.

Illness representations in caregivers of people with dementia

OBJECTIVES

Illness representations shape responses to illness experienced by the self or by others. The illness representations held by family members of those with long-term conditions such as dementia influence their understanding of what is happening to the person and how they respond and provide support. The aim of this study is to explore components of illness representations (label, cause, control and timeline) in caregivers of people with dementia.

METHOD

This was an exploratory study; the data reported came from the Memory Impairment and Dementia Awareness Study (MIDAS). Data from semi-structured interviews with 50 caregivers of people with dementia were analysed using content analysis.

RESULTS

The majority of caregivers gave accounts that appeared to endorse a medical/diagnostic label, although many used different terms interchangeably. Caregivers differentiated between direct causes and contributory factors, but the predominant explanation was that dementia had a biological cause. Other perceived causes were hereditary factors, ageing, lifestyle, life events and environmental factors. A limited number of caregivers were able to identify things that people with dementia could do to help manage the condition, while others thought nothing could be done. There were varying views about the efficacy of medication. In terms of timeline, there was considerable uncertainty about how dementia would progress over time.

CONCLUSION

The extent of uncertainty about the cause, timeline and controllability of dementia indicated that caregivers need information on these areas. Tailored information and support taking account of caregivers' existing representations may be most beneficial.

Cognitive and anatomical correlates of anosognosia in amnestic mild cognitive impairment and early-stage Alzheimer's disease

BACKGROUND

Anosognosia is a common feature in Alzheimer's disease (AD). The brain substrates of anosognosia are not fully understood, and less is known about the cognitive substrates of anosognosia in prodromal and early stages of AD.

METHODS

Fourty-seven patients with amnestic-type mild cognitive impairment (aMCI) (n = 26) and early-stage AD (n = 21) were included, and Clinical Insight Rating Scale and Anosognosia Questionnaire for Dementia (AQ-D) were used to assess anosognosia. A detailed neuropsychological battery was administered; each patient underwent a structural magnetic resonance imaging (MRI). Correlation between anosognosia and performance in individual cognitive domains as well as correlation between anosognosia and cortical thickness values in regions of interest were assessed.

RESULTS

Performance of the anosognosic patients in Digit Ordering Test (DOT), Digit Span Backwards, and Clock Drawing Test (CDT) was significantly worse compared to non-anosognosic patients in the total study population and in the aMCI subgroup but not in AD group. AQ-D scores negatively correlated with Mini-Mental State Examination (MMSE), California Verbal Learning Test (CVLT), Digit Span Backwards and CDT scores in total group and MMSE, CVLT, DOT, and Digit Span Backwards scores in the aMCI group. No significant correlations were found between cortical thickness measurements and AQ-D scores in any of the patient populations.

CONCLUSIONS

Anosognosia was associated with episodic memory, working memory, and executive functions in the total population and aMCI group, but no association was found in early-stage AD patients. Anosognosia in the early stages of AD may be related with non-structural changes such as hypoconnectivity rather than structural changes.

Social health and dementia: a European consensus on the operationalization of the concept and directions for research and practice

BACKGROUND

Because the pattern of illnesses changes in an aging population and many people manage to live well with chronic diseases, a group of health care professionals recently proposed reformulating the static WHO definition of health towards a dynamic one based on the ability to physically, mentally and socially adapt and self-manage. This paper is the result of a collaborative action of the INTERDEM Social Health Taskforce to operationalize this new health concept for people with dementia, more specifically the social domain, and to formulate directions for research and practice to promote social health in dementia.

METHOD

Based on the expertise of the Social Health Taskforce members (N = 54) three groups were formed that worked on operationalizing the three social health dimensions described by Huber et al.: (1) capacity to fulfil potential and obligations; (2) ability to manage life with some degree of independence; (3) participation in social activities. For each dimension also influencing factors, effective interventions and knowledge gaps were inventoried. After a consensus meeting, the operationalizations of the dimensions were reviewed by the European Working Group of People with Dementia (EWGPWD).

RESULTS

The social health dimensions could be well operationalized for people with dementia and are assessed as very relevant according to the Social Health Taskforce and EWGPWD. Personal (e.g. sense of coherence, competencies), disease-related (e.g. severity of cognitive impairments, comorbidity), social (support from network, stigma) and environmental factors (e.g. enabling design, accessibility) that can influence the person with dementia's social health and many interventions promoting social health were identified.

CONCLUSION

A consensus-based operationalization of social health in dementia is proposed, and factors that can influence, and interventions that improve, social health in dementia identified. Recommendations are made for research and practice.

"I Don't Think Of It As An Illness": Illness Representations in Mild to Moderate Dementia

The self-regulatory model proposes that illness representations influence adjustment and coping in chronic conditions. Better understanding of the illness representations held by people with dementia could help with targeting information and support so as to optimize adjustment and coping. In this mixed-methods study of illness representations among people with mild to moderate Alzheimer's, vascular, or mixed dementia we aimed to clarify the nature of the representations held, to determine whether specific profiles can be identified based on perceptions of the identity and cause of the condition, and to examine associations between these profiles and other participant characteristics. Data were collected in the second wave of the Memory Impairment and Dementia Awareness Study (MIDAS). Sixty-four people with dementia, who had been told their diagnosis at a memory clinic, completed interviews and responded to questionnaires. In each case a carer was also interviewed. Cluster analysis based on responses about identity and cause identified three profiles. 'Illness' cluster participants saw themselves as living with an illness and used diagnostic labels, 'ageing' cluster participants did not use diagnostic labels and viewed their difficulties as related to ageing, and 'no problem' cluster participants considered that they did not have any difficulties. 'Illness' cluster participants had better cognition and better awareness, but lower mood, and perceived more practical consequences, than 'ageing' cluster participants. Holding an 'illness' model may not be advantageous. Rather than encouraging adoption of such a model, it may be preferable to target information and select interventions in line with the person's representation profile.

Longitudinal course of behavioural and psychological symptoms of dementia: systematic review

BACKGROUND

More information about the pattern of behavioural and psychological symptoms of dementia (BPSD) in the course of dementia is needed to inform patients and clinicians and to design future interventions.

AIMS

To determine the persistence and incidence of BPSD and their relation to cognitive function, in individuals with dementia or in cohorts investigated for dementia onset.

METHOD

A systematic literature review analysed the baseline prevalence, persistence and incidence of 11 symptoms. The review was conducted according to established guidelines with the exception that we could not exclude the possibilities of bias in the studies examined.

RESULTS

The 59 included studies showed considerable heterogeneity in their objectives and methods. The symptoms hyperactivity and apathy showed high persistence and incidence; depression and anxiety low or moderate persistence and moderate incidence; and psychotic symptoms low persistence with moderate or low incidence.

CONCLUSIONS

Despite heterogeneity across studies in terms of setting, focus and length of follow-up, there were clinically relevant differences in the longitudinal courses of different BPSD. Apathy was the only symptom with high baseline prevalence, persistence and incidence during the course of dementia.

Self, cortical midline structures and the resting state: Implications for Alzheimer's disease

Different aspects of the self have been reported to be affected in many neurological or psychiatric diseases such as Alzheimer's disease (AD), including mainly higher-level cognitive self-unawareness. This higher sense of self-awareness is most likely related to and dependent on episodic memory, due to the proper integration of ourselves in time, with a permanent conservation of ourselves (i.e., sense of continuity across time). Reviewing studies in this field, our objective is thus to raise possible explanations, especially with the help of neuroimaging studies, for where such self-awareness deficits originate in AD patients. We describe not only episodic (and autobiographical memory) impairment in patients, but also the important role of cortical midline structures, the Default Mode Network, and the resting state (intrinsic brain activity) for the processing of self-related information.

Concepts and objects of awareness in Alzheimer’s disease: an updated systematic review

ABSTRACT Objectives To compare and discuss the objects of awareness in Alzheimer’s disease (AD): awareness of cognitive deficits, of functional activities, of social-emotional functioning and behavioral impairment. Methods A search in the PsycINFo, Pilots, PubMed/Medline and ISI electronic databases according to Prisma methodology was performed. We included studies about awareness in people with AD published between 2010 and 2015, with the combination of keywords: “Alzheimer AND awareness of deficits”, “Alzheimer AND anosognosia”, “Alzheimer AND insight”, “dementia AND awareness of deficits”, “dementia AND anosognosia”, “dementia AND insight”. The articles were categorized according to the specific object of awareness. Results Seven hundred and ten records were identified and, after application of the exclusion criteria, 191 studies were retrieved for potential use. After excluding the duplicates, 46 studies were included. Most studies assessed the cognitive domain of awareness, followed by the functional, social-emotional, and behavioral impairment domains. Memory deficits were not sufficient to explain impaired awareness in AD. Longitudinal studies did not find discrepancies between patients and caregivers’ reports, indicating that awareness is not related to cognition. Conflicting findings were observed, including the relation between awareness, mood, severity of disease, and personal characteristics. Conclusions The studies show lack of conceptual consensus and significant methodological differences. The inclusion of samples without differentiation of dementia etiology is associated to symptomatic differences, which affect awareness domains. Awareness in AD is a complex and multidimensional construct. Different objects elicit different levels of awareness.

Temporal course and pathologic basis of unawareness of memory loss in dementia

OBJECTIVE

To characterize the natural history and neuropathologic basis of unawareness of memory loss in late-life dementia.

METHODS

Analyses are based on 2,092 older persons from 3 longitudinal clinical-pathologic cohort studies who had no memory or cognitive impairment at baseline. Annual evaluations included clinical classification of dementia plus self-rating and performance testing of memory. At death, there was a uniform neuropathologic examination to quantify 7 dementia-related pathologies.

RESULTS

In the full group, memory ratings were modestly correlated with memory performance (intercepts r = 0.26, p < 0.001; slopes r = 0.23, p < 001) and so we regressed each person's memory performance on their memory ratings, and the residuals provided longitudinal indicators of memory awareness. In a subset of 239 persons who developed dementia, episodic memory awareness was stable until a mean of 2.6 years before dementia onset (95% credible interval -2.7, -1.6); thereafter, memory awareness declined rapidly (mean annual change -0.32, 95% credible interval -0.37, -0.28). Older age at baseline was associated with later onset of memory unawareness. In a subset of 385 persons who died and underwent neuropathologic examination, transactive response DNA-binding protein 43 (TDP-43) pathology, tau tangles, and gross cerebral infarcts were related to decline in memory awareness. In the absence of these pathologies, no decline in memory awareness was evident. Results were similar in subgroups with and without dementia.

CONCLUSIONS

Awareness of memory impairment typically begins to decline about 2-3 years before dementia onset and is associated with postmortem evidence of TDP-43 pathology, tangles, and gross cerebral infarcts.

Activities of daily living and quality of life across different stages of dementia: a UK study

OBJECTIVES

People with dementia (PwD) require an increasing degree of assistance with activities of daily living (ADLs), and dependency may negatively impact on their well-being. However, it remains unclear which activities are impaired at each stage of dementia and to what extent this is associated with variations in quality of life (QoL) across the different stages, which were the two objectives of this study.

METHODS

The sample comprised 122 PwD, and their carers, either living at home or recently admitted to long-term care. Measures of cognition and QoL were completed by the PwD and proxy measures of psychopathology, depression, ADLs and QoL were recorded. Using frequency, correlation and multiple regression analysis, data were analysed for the number of ADL impairments across mild, moderate and severe dementia and for the factors impacting on QoL.

RESULTS

ADL performance deteriorates differently for individual activities, with some ADLs showing impairment in mild dementia, including dressing, whereas others only deteriorate later on, including feeding. This decline may be seen in the degree to which carers perceive ADLs to explain the QoL of the PwD, with more ADLs associated with QoL in severe dementia. RESULTS of the regression analysis showed that total ADL performance however was only impacting on QoL in moderate dementia.

CONCLUSION

Knowledge about performance deterioration in different ADLs has implications for designing interventions to address specific activities at different stages of the disease. Furthermore, findings suggest that different factors are important to consider when trying to improve or maintain QoL at different stages.

Longitudinal changes in awareness over 36 months in patients with mild Alzheimer's disease

BACKGROUND

Longitudinal changes in awareness in dementia have been studied with short follow-up time and mostly in small patient groups (including patients with moderate dementia). We investigated awareness in patients with mild Alzheimer's disease (AD) over 36 months and studied if a decline in awareness was associated with decline in cognition and increase in neuropsychiatric symptoms.

METHODS

Awareness was measured on a categorical scale in 95 AD patients (age ≥50 years, Mini-Mental State Examination (MMSE) score ≥20). Awareness was rated at three time points (follow-up at 12 and 36 months) where MMSE, Neuropsychiatric Inventory (NPI-Q), and Cornell scale for Depression in Dementia also were applied.

RESULTS

At 12 months, 26% had lower awareness rating as compared to baseline and at 36 months lower awareness ratings were found in 39%. At both visits, 16% had higher awareness rating as compared to baseline. Patients with lower awareness at 36 months as compared to baseline had a more rapid increase in NPI-Q score (p = 0.002) over 36 months as compared to patients with stable or improved awareness over 36 months. A more rapid decline in MMSE score was observed for patients with lower awareness at 36 months (as compared to baseline) but only when compared to patients in whom awareness improved over time.

CONCLUSIONS

The results show essentially no clear relationship between cognitive decline over three years and awareness. In some cases, awareness remained stable or even improved despite significant cognitive decline. In the subgroup where awareness declined over time, overall ratings of neuropsychiatric symptoms declined more rapidly than in the remaining patients.