Comprehensive geriatric assessment in elderly patients with dementia

Health-Related Quality of Life among Older Adults with Dementia Living in Vietnamese Nursing Homes

Better understanding of the quality of life among nursing home residents with dementia is important for developing interventions. The objectives of this cross-sectional study were to examine factors associated with poor health-related quality of life in older people with dementia living in nursing homes in Hanoi, Vietnam. In-person interviews were conducted with 140 adults who were 60 years and older with dementia, and information about their quality of life was obtained using the Quality of Life in Alzheimer's Disease (QOL-AD) scale. The sociodemographic and clinical factors associated with poor health-related quality of life (lowest quartile) were assessed through the results of physical tests, interviews with nursing home staff, and review of medical records. The average age of the study sample was 78.3 years, 65% were women, and their average QOL-AD total score was 27.3 (SD = 4.4). Malnutrition, total dependence in activities of daily living, and urinary incontinence were associated with poor quality of life after controlling for multiple potentially confounding factors. Our findings show that Vietnamese nursing home residents with dementia have a moderate total quality of life score, and interventions based on comprehensive geriatric assessment remain needed to modify risk factors related to poor health-related quality of life.

Comprehensive Geriatric Care in Older Adults: Walking Ability after an Acute Fracture

BACKGROUND/OBJECTIVES

Comprehensive Geriatric Care (CGC) is a specific multimodal treatment for older patients. In the current study, we aimed to investigate walking performance after CGC in medically ill patients versus those with fractures.

METHODS

The timed up and go test (TuG), a 5-grade scale assessment (1 = no walking impairment to 5 = no walking ability at all) for evaluating individual walking ability was performed in all patients who underwent CGC prior to and after treatment. Factors associated with improvement in walking ability were analyzed in the subgroup of patients with fractures.

RESULTS

Out of 1263 hospitalized patients, 1099 underwent CGC (median age: 83.1 years (IQR 79.0-87.8 years); 64.1% were female). Patients with fractures (n = 300) were older than those without (n = 799), (median 85.6 versus 82.4 years, p = 0.001). Improvement in TuG after CGC was found in 54.2% of the fracture patients compared to just 45.9% of those without fractures. In fracture group patients, TuG improved from median 5 on admission to median 3 on discharge (p = 0.001). In fracture patients, improvement in walking ability was associated with higher Barthel index values on admission (median 45 (IQR: 35-55) versus 35 (IQR: 20-50): p = 0.001) and Tinetti assessment scores (median 9 (IQR: 4-14.25) versus 5 (IQR: 0-13); p = 0.001) and was negatively associated with the diagnosis of dementia (21.4% versus 31.5%; p = 0.058).

CONCLUSION

CGC improved walking ability in more than half of all patients examined. Older patients in particular might benefit from undergoing the procedure after an acute fracture. A better initial functional status favors a positive result following the treatment.

Multidisciplinary pharmacotherapy collaboration for home-based older adults with dementia: a study focusing on physicians, pharmacists, and nursing professionals

BACKGROUND

It is imperative that a team consisting of a physician, pharmacist, and nursing professional provides pharmacotherapy support to achieve the optimal effect of pharmacotherapy for older adults with dementia. This study reviewed Japanese publications on the process of pharmacotherapy support practised by various professionals for home-based older adults with dementia and investigated healthcare professionals' perceived importance and practice of pharmacotherapy support.

METHODS

This study aimed to shed light on basic pharmacotherapy support for behavioural and psychological symptoms among home-based older adults with dementia using multidisciplinary collaboration, through a literature review of Japanese publications. Based on the literature review, 13 items pertaining to basic pharmacotherapy support for home-based older adults with dementia were extracted. A mail-based, self-administered, anonymous questionnaire survey was conducted with professionals including physicians, pharmacists, and nursing professionals who provide pharmacotherapy support to home-based older adults with dementia. Participants rated 13 items on their perceived importance and practice of basic pharmacotherapy support using a four-point Likert scale.

RESULTS

The results indicated that participants recognised the importance of all 13 items. At least 80% of all professionals indicated that they practised seven out of 13 items. Less than 80% of all professionals indicated they practised the other six items that should be provided after the commencement of pharmacotherapy. A relatively high proportion of nursing professionals (70%) indicated they practised the remaining six items. The 13 items were indeed deemed important for characterising pharmacotherapy support. However, in Japan, suboptimal support is provided following the commencement of medication. This may be because appropriate modifications to dementia care are not made as the patient's condition progresses.

CONCLUSIONS

It is suggested that multidisciplinary collaboration focusing on the progression of dementia and the process of pharmacotherapy, especially after the commencement of pharmacotherapy, may help provide effective, continuous pharmacotherapy.

Polypharmacy is associated with functional decline in Alzheimer's disease and Lewy body dementia

BACKGROUND

In dementia, a number of factors may influence functional decline in addition to cognition. In this study, we aimed to study the potential association of the number of prescribed medications with functional decline trajectories over a five-year follow-up in people diagnosed with mild Alzheimer's disease (AD) or Lewy Body dementia (LBD).

METHODS

This is a longitudinal analysis of a Norwegian cohort study entitled "The Dementia Study of Western Norway". We included 196 patients newly diagnosed with AD (n=111) and LBD (n=85), followed annually for 5 years. We conducted linear mixed-effects models to analyse the association of the number of medications with functional decline measured by the Rapid Disability Rating Scale - 2.

RESULTS

The mean prescribed medications at baseline was 4.18∓2.60, for AD 3.92∓2.51 and LBD 4.52∓2.70. The number of medications increased during the follow-up; at year five the mean for AD was 7.28∓4.42 and for LBD 8.11∓5.16. Using more medications was associated with faster functional decline in AD (Est 0.04, SE 0.01, p-value 0.003) and LBD (Est 0.08, SE 0.03, p-value 0.008) after adjusting for age, sex, comorbidity, neuropsychiatric symptoms, and cognition. For each medication added during the follow-up, functional trajectories worsened by 1% for AD and 2% for LBD. The number of medications was not associated with cognitive decline.

CONCLUSION

We found that higher number of medications was related to a faster functional decline, both in AD and LBD. With disease progression, there was an increase in the number of medications. Prescription in dementia should be carefully assessed, possibly improving the functional prognosis.

Improved Balance and Gait Ability and Basic Activities of Daily Living after Comprehensive Geriatric Care in Frail Older Patients with Fractures

(1) Purpose: Comprehensive geriatric care (CGC) is a multidisciplinary treatment approach for elderly patients. We aimed to investigate outcomes in fracture patients who had been treated using this approach in a large geriatric unit. (2) Methods: This observational cohort study assessed the gait function (using the Tinetti Balance and Gait Test (TBGT)) and basic activities of daily living (ADL) (using the Barthel index (BI)) before and after CGC and compared the results. Baseline data, walking ability assessments (Timed Up and Go, TUG), and cognitive status (mini mental status examination, MMSE) were also analyzed in the subgroup of patients with versus without fractures. (3) Results: Out of 1263 hospitalized patients, 1099 received CGC (median age: 83.1 years (IQR: 79.0–87.8 years); 64.1% were female). TBGT improvement was observed in 90.7% and BI increased in 82.7% of fracture patients. A TBGT improvement of >5 was noted in 47.3% and was associated with female sex, a lower BI at admission (median: 40 versus 45; p = 0.010), and poorer mobility on admission (TUG: median 5 versus 4; p = 0.001). An improvement in BI of ≥15 was observed in 63.0% of the cases, and was associated with a better cognitive status (MMSE: median 25 versus 18; p = 0.001) and inversely associated with diabetes mellitus and a previous stroke. (4) Conclusion: CGC in specialized geriatric units improves the balance and gait and the basic ADL in geriatric patients. After fracture, female patients are more likely to experience improvements in gait and balance, while patients with better cognitive condition are more likely to experience improvements in ADL.

Use of day services improved cognitive function in patients with Alzheimer's disease

AIM

Day services (DS) are part of the public nursing care system in Japan. The purpose of DS is to help elderly individuals maintain mental and physical functions, eliminate feelings of isolation among homebound users, and reduce the burden of care on family members. However, the relationship between DS and the progression of Alzheimer's disease (AD) remains unclear.

METHODS

We retrospectively analyzed 161 AD patients based on available Mini-Mental State Examination (MMSE) scores. The patients were divided into two groups: those who started to use DS (n = 106) and those who did not use DS (n = 55). We then compared the groups' MMSE scores between the first memory clinic visit and the 6-month point.

RESULTS

There were no significant differences between the two groups with regard to sex and the number of family members, but the non-DS group was younger, had more education, and had better MMSE scores at the first visit. At 6 months, we found a significant improvement in the MMSE scores of DS users, reflecting improved cognitive function. In addition, lower MMSE score at the first visit was associated with greater improvement in MMSE score at 6 months. Interestingly, the frequency of DS use had no significant effect on MMSE score. However, after approximately 6 months, DS use significantly improved the cognitive function of AD patients.

CONCLUSIONS

DS use significantly improved the cognitive function of AD patients. However, most DS users in Japan are older and have severe dementia. Patients who are younger, have more education, or have mild dementia dislike using DS. As a significant difference was found in the MMSE scores between the two groups after 6 months, DS use appears to be a useful non-drug therapy.

Japanese Old Stories Cognitive Scale: a screening test to detect cognitive disease and prompt visiting a memory clinic

BACKGROUND

Early detection and diagnosis is critical in enhancing treatment outcomes for those with cognitive disease. However, most Japanese patients are averse to visiting mental health clinics or taking cognitive screening examinations. A new simple screening test is needed that is acceptable to patients and encourages them to visit a memory clinic if indicated.

METHODS

We developed a brief screening examination, consisting of four common Japanese old stories, for detection of cognitive disease. A total of 311 patients at three outpatient memory clinics completed the screening test, responding to a 10-question, fill-in-the-blanks assessment. Questions were read aloud to patients with visual impairment, and we transcribed the spoken responses of patients who were physically incapable of writing. The Hasegawa Dementia Scale-Revised (HDS-R) and Mini-Mental State Examination (MMSE) were administered at the same time.

RESULTS

Using the developed Japanese Old Stories Cognitive Scale (JOSS), we found significant differences between dementia and control or mild cognitive impairment (MCI) groups. The JOSS was less affected by education level than the HDS-R or MMSE, possibly because Japanese old stories are usually learned from family members during preschool years. The JOSS may be able to detect remote memory disturbance in addition to other cognitive dysfunctions.

CONCLUSIONS

Most patients with AD, even in advanced stages, are averse to visiting a memory clinic because it can be difficult to accept any resulting diagnosis of cognitive disease. JOSS is a quick and simple screening tool to gather evidence of cognitive dysfunction and prompt a referral to a memory clinic. Patients with cognitive disease found the JOSS acceptable, and its high specificity could be useful in encouraging patients to visit already-crowded memory clinics for formal diagnosis and intervention.

White matter hyperintensities and geriatric syndrome: An important role of arterial stiffness

White matter hyperintensities (WMH) are defined as cerebral white matter changes presumed to be of vascular origin, bilateral and mostly symmetrical. They can appear as hyperintense on T2-weighted and fluid-attenuated inversion recovery sequences, and as isointense or hypointense on T1-weighted magnetic resonance imaging of the brain. WMH have been focused on because of their clinical importance as a risk factor for cerebrovascular diseases and cognitive impairment. WMH are associated with geriatric syndrome, which is defined by clinical symptoms characteristic of older adults, including cognitive and functional impairment and falls. Cerebral small vessel diseases, such as WMH, might play an important role as risk factors for cerebrovascular diseases, cognitive impairment and geriatric syndrome through the mechanism of arterial stiffness. However, the vascular, physiological and metabolic roles of arterial stiffness remain unclear. Basically, arterial stiffness indicates microvessel arteriosclerosis presenting with vascular endothelial dysfunction. These changes might arise from hemodynamic stress as a result of a "tsunami effect" on cerebral parenchyma. In the present article, we review the clinical characteristics of WMH, focusing particularly on two associations: (i) those between cerebral small vessel diseases including WMH and arterial stiffness; and (ii) those between WMH and geriatric syndrome.

Oxidative stress and inflammation are associated with physical frailty in patients with Alzheimer's disease

AIMS

Dementia is closely connected with frailty, and these two conditions are common in older adults. However, the biological mechanism that causes frailty in patients with Alzheimer's disease (AD) is not fully understood. We determined whether oxidative stress and inflammatory mechanisms could be associated with physical frailty in patients with AD.

METHODS

We studied 140 elderly outpatients with mild-to-moderate AD. Frailty status was determined according to the presence of the following five measurable characteristics: weight loss, exhaustion, low physical activity, slowness and weakness. We measured oxidative stress markers, including plasma levels of diacron reactive oxygen metabolite and biological anti-oxidant potential, endogenous plasma anti-oxidants, such as albumin, bilirubin and uric acid, and urinary 8-hydroxy-2'-deoxyguanosine (8-OHdG) and 8-epiPGF2α (8-isoprostane), and inflammatory markers, including interleukin-6 and tumor necrosis factor-α.

RESULTS

Among patients, 44 (31%) were non-frail, 62 (44%) were prefrail and 34 (24%) were frail. Frail and prefrail patients were older, more likely to be women and had more comorbid medical conditions than non-frail patients. Frail or prefrail patients showed significantly higher diacron reactive oxygen metabolite and lower biological anti-oxidant potential levels, a significant decrease in bilirubin, a significant increase in urinary 8-OHdG and 8-isoprostane levels, and a significantly higher interleukin-6 level, in contrast to non-frail patients.

CONCLUSIONS

Physical frailty is common in old and female AD patients with comorbid medical diseases. The present results strongly suggest that oxidative stress and inflammation are involved in the pathophysiology of frailty status in individuals with AD. Geriatr Gerontol Int 2017; 17: 913-918.