Alzheimer's disease: the impact of the family on spouses, offspring, and inlaws

Characterizing dysregulations via cell-cell communications in Alzheimer's brains using single-cell transcriptomes

BACKGROUND

Alzheimer's disease (AD) is a devastating neurodegenerative disorder affecting 44 million people worldwide, leading to cognitive decline, memory loss, and significant impairment in daily functioning. The recent single-cell sequencing technology has revolutionized genetic and genomic resolution by enabling scientists to explore the diversity of gene expression patterns at the finest resolution. Most existing studies have solely focused on molecular perturbations within each cell, but cells live in microenvironments rather than in isolated entities. Here, we leveraged the large-scale and publicly available single-nucleus RNA sequencing in the human prefrontal cortex to investigate cell-to-cell communication in healthy brains and their perturbations in AD. We uniformly processed the snRNA-seq with strict QCs and labeled canonical cell types consistent with the definitions from the BRAIN Initiative Cell Census Network. From ligand and receptor gene expression, we built a high-confidence cell-to-cell communication network to investigate signaling differences between AD and healthy brains.

RESULTS

Specifically, we first performed broad communication pattern analyses to highlight that biologically related cell types in normal brains rely on largely overlapping signaling networks and that the AD brain exhibits the irregular inter-mixing of cell types and signaling pathways. Secondly, we performed a more focused cell-type-centric analysis and found that excitatory neurons in AD have significantly increased their communications to inhibitory neurons, while inhibitory neurons and other non-neuronal cells globally decreased theirs to all cells. Then, we delved deeper with a signaling-centric view, showing that canonical signaling pathways CSF, TGFβ, and CX3C are significantly dysregulated in their signaling to the cell type microglia/PVM and from endothelial to neuronal cells for the WNT pathway. Finally, after extracting 23 known AD risk genes, our intracellular communication analysis revealed a strong connection of extracellular ligand genes APP, APOE, and PSEN1 to intracellular AD risk genes TREM2, ABCA1, and APP in the communication from astrocytes and microglia to neurons.

CONCLUSIONS

In summary, with the novel advances in single-cell sequencing technologies, we show that cellular signaling is regulated in a cell-type-specific manner and that improper regulation of extracellular signaling genes is linked to intracellular risk genes, giving the mechanistic intra- and inter-cellular picture of AD.

The Israel Registry for Alzheimer's Prevention (IRAP) Study: Design and Baseline Characteristics

BACKGROUND

Family history of Alzheimer's disease (AD) is associated with increased dementia-risk.

OBJECTIVE

The Israel Registry for Alzheimer's Prevention (IRAP) is a prospective longitudinal study of asymptomatic middle-aged offspring of AD patients (family history positive; FH+) and controls (whose parents have aged without dementia; FH-) aimed to unravel the contribution of midlife factors to future cognitive decline and dementia. Here we present the study design, methods, and baseline characteristics.

METHODS

Participants are members of the Maccabi Health Services, 40-65 years of age, with exquisitely detailed laboratory, medical diagnoses and medication data available in the Maccabi electronic medical records since 1998. Data collected through IRAP include genetic, sociodemographic, cognitive, brain imaging, lifestyle, and health-related characteristics at baseline and every three years thereafter.

RESULTS

Currently IRAP has 483 participants [mean age 54.95 (SD = 6.68) and 64.8% (n = 313) women], 379 (78.5%) FH+, and 104 (21.5%) FH-. Compared to FH-, FH+ participants were younger (p = 0.011), more often males (p = 0.003) and with a higher prevalence of the APOE E4 allele carriers (32.9% FH+, 22% FH-; p = 0.040). Adjusting for age, sex, and education, FH+ performed worse than FH-in global cognition (p = 0.027) and episodic memory (p = 0.022).

CONCLUSION

Lower cognitive scores and higher rates of the APOE E4 allele carriers among the FH+ group suggest that FH ascertainment is good. The combination of long-term historical health-related data available through Maccabi with the multifactorial information collected through IRAP will potentially enable development of dementia-prevention strategies already in midlife, a critical period in terms of risk factor exposure and initiation of AD-neuropathology.

Neurocognitive Impairment: Addressing Couple and Family Challenges

Conditions involving neurocognitive impairment pose enormous challenges to couples and families. However, research and practice tend to focus narrowly on immediate issues for individual caregivers and their dyadic relationship with the affected member. A broad family systems approach with attention to family processes over time is needed in training, practice, and research. In this paper, Rolland's Family Systems Illness model provides a guiding framework to consider the interaction of different psychosocial types of neurocognitive conditions and their evolution over time with individual, couple, and family life-course development. Discussion addresses key family and couple issues with mild-to-severe cognitive impairment and progressive dementias, including: communication, multigenerational legacies, threatened future neurocognitive disability, ambiguous loss, decisional capacity, reaching limits, placement decisions, issues for adult children and spousal caregivers, and the transformation of intimate bonds. Principles and guidelines are offered to help couples and families master complex challenges, deepen bonds, and forge positive pathways ahead.

Caregiver burden in Alzheimer-type dementia and psychosis: A comparative study from India

BACKGROUND

Caregiver burden in dementia is an important area of research. Providing care for a relative can be a potent source of chronic stress and can have deleterious consequences for both the physical and emotional health of caregivers. This study aims to evaluate the burden of care in caregivers of patients with Alzheimer-type dementia and compare it with elderly psychosis; and to also study the factors that influence burden of care in Alzheimer's dementia.

METHODS

Thirty-two caregiver-patient dyads of Alzheimer-type dementia were compared with thirty-two caregiver-patient dyads of psychosis. Cognitive assessment, abilities to perform activities of daily living and severity of dementia was assessed in the patients. Zarit Burden Interview was used to study the caregiver burden in both groups.

RESULTS

The mean burden score in dementia caregivers was high at 47.7, whereas the mean burden score for elderly psychosis caregivers was lesser at 33.6, and this difference in mean burden scores was found to be statistically significant. Spouses had the highest mean burden scores of 53.48. Caregiver burden in dementia was positively correlated with cognitive impairment and inability to carry out ADLs. Presence of psychological distress in caregivers was also an indicator for greater caregiver burden in dementia.

CONCLUSION

The study revealed that dementia carries a greater caregiver burden when compared with elderly patients with psychosis. Innovative interventions are needed to remove burden from caregiving, making it a meaningful practice integral to the Indian society.

'Nobody would say that it is Alzheimer's or dementia at this age': Family adjustment following a diagnosis of early-onset dementia

OBJECTIVES

Family interaction and intergenerational dynamics have been known to influence the efficacy of therapeutic interventions and as such, the understanding of such dynamics in the experience of transitions can assist in strengthening the support provided to families living with such diagnoses. As such, the aims and objectives of this work were to develop a deeper understanding of family transition in early-onset dementia and to construct a representative model of this experience.

METHOD

This qualitative study used an 'initial-and-follow-up' interview design with semi-structured in-depth interviews in participants' homes. A framework approach to qualitative data analysis was used in order to identify important points of transition in the family experience of early-onset dementia and how families frame and respond to their own health expectations.

RESULTS

Nine families provided written informed consent to participate in the study. The nine participating families were made up of 20 participants, including nine spousal pairs and two young adult children. Each family participated in two research interviews in their individual homes. Four major themes emerged from the data: Diagnosis; Finances; Relationships; and Meaningful Activity.

CONCLUSION

Transitions experienced by families in early-onset dementia can be significantly impacted by the opportunity and availability of meaningful activity and/or a purposeful role. Not only does this activity benefit both the person with dementia and their family, but also supports much needed home and community living for people with dementia, as demonstrated by predicted future bed shortages in Canadian hospitals and long term care facilities.

Beyond Strain: Personal Strengths and Mental Health of Mexican and Argentinean Dementia Caregivers

INTRODUCTION

Life expectancy is increasing in Latin America resulting in the need for more family caregivers for older adults with dementia. The purpose of the current study was to examine the relationships between personal strengths (optimism, sense of coherence [SOC], and resilience) and the mental health of dementia caregivers from Latin America.

METHOD

Primary family dementia caregivers (n = 127) were identified via convenience sampling at the Instituto de Neurociencias de San Lucas, Argentina, and CETYS University, in Baja California, Mexico and completed measures of these constructs.

FINDINGS

Personal strengths explained between 32% and 50% of the variance in caregiver mental health. In a series of hierarchical multiple regressions, more manageability (β = -.38, p = .001), general resilience (β = -.24, p = .012), and social competence (β = -.21, p = .034) were uniquely associated with lower depression. Greater comprehensibility (β = -.28, p = .008) was uniquely associated with decreased burden, and manageability was marginally related (β = -.21, p< .10). Greater optimism (β = .37, p< .001) and manageability (β = .27, p = .004) were uniquely associated with increased life satisfaction.

DISCUSSION

The personal strengths of caregivers in Latin America may be particularly important for their mental health because of the culturally imbedded sense of duty toward older family members.

IMPLICATIONS

Incorporating strengths-based approaches into research on caregiver interventions in regions where caregiving is a highly culturally valued role such as Latin America may have the potential to improve the mental health of dementia caregivers.

Caregiving networks-using a network approach to identify missed opportunities

OBJECTIVES

This study demonstrates the added value to caregiving research by using a multi-informant social network approach within the context of Alzheimer's disease and related dementia.

METHOD

Sixty-six informants from 24 families enumerated caregiving network members in 2012. Comparisons were made between networks based on a single informant versus multiple informants in terms of network composition and caregiving roles, core-periphery structure, and identification of "missed opportunities" in recruitment.

RESULTS

On average, each informant beyond the index enumerated 6.2 new members, resulting in about 10 new members per family network when the multiple-informant approach is used. Compared with index informants' networks, multi-informant networks showed an 85% increase in identification of direct care providers (1.71 compared with 3.42) and a 48% increase in identification of those involved in care decision making (3.33 compared with 4.92). Informants from the same network generally showed agreement in reported participation in caregiving activities. However, the reports of non-participation in these roles were less consistent among the informants. Resulting structure indicated a core caregiving network (M = 6.12 members), with semi-peripheral and peripheral members (M = 5.19 and M = 14.83 members, respectively).

DISCUSSION

Results suggest that an iterative, targeted sampling approach with at least three informants allows for a more comprehensive assessment of caregiving processes. Applying this approach in future research will greatly enhance our knowledge and better inform future interventions to facilitate family adaptation.

'It's nice to have something to do': early-onset dementia and maintaining purposeful activity

As the global focus on dementia care increases due to the demand on health, social, legal and financial services, it is imperative to further understand the experience of those living with a diagnosis of dementia. There is a particular lack of research focused on younger people (under the age of 65 years) with dementia and virtually none focuses on the experience of the family unit. The literature suggests that periods of transition place significant stressors on families living with dementia. One such transition is the transition out of perceived purposeful activity, be this employment or voluntary work. This transition was explored during the course of a qualitative repeated interview study with younger people with dementia and their families. Nine families (20 participants) took part in semi-structured research interviews that were transcribed and analyzed using a Framework approach to qualitative analysis. Meaningful Activity emerged as a major theme through this analysis. Two subthemes also emerged: (1) the traumatic cessation of work; and (2) the need for purposeful activity. These themes have significant clinical implications as maintaining a purposeful role through high-quality, age-specific dementia services may decrease the direct and indirect costs of dementia to global economies.

Review of family therapy and dementia: twenty-five years on

BACKGROUND

We reviewed the literature on family therapy and dementia to investigate the following: what is known about the use of family therapy in the context of living with dementia; what are the challenges of working in this context; and what guidelines/models are available to guide family therapists working with families living with dementia.

METHODS

We searched English language literature from 1992 onwards, classified the resulting papers into broad categories of theoretical, expository, or research (descriptive, quantitative, or qualitative), and conducted a narrative review to draw learning points from the identified papers.

RESULTS

In total 31 papers were identified: five theoretical, 11 expository; and 15 research papers. Several papers described methodologies; psychotherapeutic interventions applied to family members; or complex intervention packages in which the role of family therapy could not be separately identified, rather than family therapy. A range of outcomes were investigated, often involving the caregiver. Several authors suggest areas in dementia care where family therapy is likely to be beneficial.

CONCLUSIONS

Although the literature on family therapy and dementia has grown over the past 25 years and suggests potentially useful roles for therapy, a number of challenges exist in terms of context, family, and therapy itself. There is a need for further research, particularly into the following fields: How to evaluate the success of therapy; how to ensure treatment integrity; how to make techniques from family therapy available more widely; and how to train the health and social care workforce in working with families.

Family-AiD: a family-centred assessment tool in young-onset dementia

Purpose

– Standards of care and care pathways for younger people with dementia vary greatly, making clinical development and service planning challenging. Staff working in dementia services identify that they use biographical knowledge of families to influence clinical decision making. This information is not collected or implemented in a formal manner; highlighting an important knowledge-practice gap. The paper aims to discuss these issues.

Design/methodology/approach

– The development of a family-centred assessment for use in dementia care has three core components: first, thematic development from qualitative interviews with younger people with dementia and their families; second, clinical input on a preliminary design of the tool; and third, feedback from an external panel of clinical and methodological experts and families living with young-onset dementia.

Findings

– The 12-item Family Assessment in Dementia (Family-AiD) tool was developed and presented for clinical use. These 12 questions are answered with a simple Likert-type scale to determine areas of unmet need and identify where families may need additional clinical support. Also included is a series of open-ended questions and a biographical timeline designed to assist staff with the collection and use of biographical and family functioning information.

Originality/value

– A dementia-specific clinical family assessment tool, which also collects background biographical data on family units may be a useful way to document information; inform clinical decision making; and address otherwise unmet needs. Family-AiD has potential to improve clinical care provision of people with dementia and their families. Evaluation of the feasibility and acceptability of its implementation in practice are now required.

Linking family dynamics and the mental health of Colombian dementia caregivers

This cross-sectional, quantitative, self-report study examined the relationship between family dynamics (cohesion, flexibility, pathology/ functioning, communication, family satisfaction, and empathy) and mental health (depression, burden, stress, and satisfaction with life [SWL]) in 90 dementia caregivers from Colombia. Hierarchical multiple regressions controlling for caregiver demographics found that family dynamics were significantly associated with caregiver depression, stress, and SWL and marginally associated with burden. Within these regressions, empathy was uniquely associated with stress; flexibility with depression and marginally with SWL; and family communication marginally with burden and stress. Nearly all family dynamic variables were bivariately associated with caregiver mental health variables, such that caregivers had stronger mental health when their family dynamics were healthy. Family-systems interventions in global regions with high levels of familism like that in the current study may improve family empathy, flexibility, and communication, thereby producing better caregiver mental health and better informal care for people with dementia.

Family triad perceptions of mild cognitive impairment

OBJECTIVES

We examined subjective perceptions of memory loss among older adults with mild cognitive impairment (MCI) and two other relatives in order to improve understanding of family coping. We also investigated contextual conditions associated with perceptions of family dynamics and relationships.

METHOD

We conducted interviews with 56 family triads (the elder with MCI, the primary care partner, and a secondary care partner). Guided by Pearlin and colleagues' caregiving stress process framework, questions addressed perceptions of memory changes and interpretation of the effects of MCI on family interaction patterns.

RESULTS

Analyses of family triads revealed four degrees of the extent to which family members similarly acknowledged elders' MCI. The acknowledgment groups differed on history of family dynamics, experience with dementia, and perceived extent of memory change in the elder. Families characterized by full acknowledgment coped better with perceived changes in the elder's functioning than those in which members' perceptions of MCI were incongruent.

DISCUSSION

Pursuing family-level data on responses to MCI uncovered more nuanced reactions, often differing across triad members, than individual-based research has found. Family perceptions about changes in elders' memory have important implications for within-family interactions and support that can help families cope successfully with MCI.

Young children in early-onset Alzheimer's disease families: research gaps and emerging service needs

Early-onset Alzheimer's disease (EOAD), defined as affecting those under age 65, afflicts between 200,000 and 500,000 people in the US. EOAD tends to be a fast-progressing and aggressive form of AD. There is a beginning body of research exploring EOAD patients' experience and needs, as well as that of their primary family caregivers, often spouses. However, there has been very little written about the experience and needs of EOAD patients' children, who because of the early onset, and increasing postponement of childbearing, may be latency-aged or in their early teens. This paper reviews existing and related literature in this area, and illustrates the psychosocial impact on children using the case of a 50 year-old father diagnosed with AD and his 16 year-old daughter and 11 year-old son. The need for increased research and program development to address these children's needs is discussed.

“My Grandparent Has Dementia”

The study examined the grandparent–grandchild relationship when the grandparent has dementia. Grandchildren living in Barcelona, Spain, participated in the study ( n = 145). These participants completed a questionnaire that included questions on: (a) the frequency of 15 emotions they may have experienced in this relationship, (b) their current relationship with a grandparent who has dementia (frequency of contact, emotional closeness, and satisfaction with the relationship), and (c) perception of changes in the relationship. Results showed that the dementia process has a negative impact on the relationship between grandparent and grandchildren. However, in some cases, there was also potential for positive changes, which are mainly related to the ability to keep emotional contact and express positive emotions. Findings suggested the need to take into account grandchildren when planning training programs for families caring for relatives with dementia, such as providing information about the disease and improving their coping strategies.

Gender differences in caregiver stressors, social resources, and health: an updated meta-analysis

This meta-analysis integrates results from 229 studies on gender differences in caregiver psychological and physical health, caregiving stressors, and social resources. Contrary to common perceptions, gender differences in caregiving variables were small to very small. Women had higher levels of burden and depression, and lower levels of subjective well-being and physical health. They reported that their care recipient had more behavioral problems; they provided more caregiving hours, helped with more caregiving tasks, and assisted with more personal care. Women and men did not differ in the use of informal and formal support. Statistically controlling for gender differences in stressors and resources reduced the size of gender differences in depression and physical health to levels that have been observed in noncaregiving samples. The results support stress-and-coping theories on gender differences in caregiving.

Burden among family caregivers of persons with Alzheimer's disease in nursing homes

PURPOSE

This article examines family caregiver burden after placement of a relative with Alzheimer's disease or a related dementia in a nursing home.

DESIGN AND METHODS

A systems-oriented contextual approach was used to study burden in 276 family caregivers.

RESULTS

SAS PROC MIXED analysis showed burden to be associated with caregiver age, length of time involved in caregiving, custodial units, involvement in hands-on care, and expectations for care.

IMPLICATIONS

The findings suggest that more services aimed at relieving caregiver burden after nursing home placement may be warranted, particularly so for caregivers who are older and for those who had a shorter length of involvement in direct caregiving before institutionalization.

The family and type 2 diabetes: a framework for intervention

Four broad groups of factors have been linked with self-management behavior in type 2 diabetes over time: (1) characteristics of patients, (2) amount and management of stress, (3) characteristics of providers and provider-patient relationships, and (4) characteristics of the social network/context in which disease management takes place. Of these four, social network/context has received the least amount of study and has been described in terms not easily applicable to intervention. In this paper, we identified the social network/context of diabetes management as residing within the family. We defined the family for clinical purposes, reviewed the literature concerning what is known about the link between properties of the family context of care and outcomes in type 2 diabetes and other chronic diseases, and identified areas of family life that are relevant to diabetes management. This information was then used to demonstrate how a family context of care can serve as a clinical framework for integrating all four groups of factors that affect disease management. Implications of this approach for practice and research are described.

Social issues of the Alzheimer's patient and family

Families caring for a person with Alzheimer's disease (AD) soon discover that it is unlike any other illness. Coping with a degenerative brain disease is much different than dealing with a physical disability. AD is more disruptive to, and has greater impact on, the family than other chronic diseases. AD caregiving carries with it a high financial, social, and emotional price. Families must work toward effectively coping with the disease, decreasing the harmful effects on the family, and keeping family conflicts to a minimum. Support groups can provide families with much-needed information on the disease, emotional and practical support, and an expressive or advocacy outlet. Formal services can help relieve some of the burden of caring for an AD patient. Family members must remember that there is no "right" way to care for a person with AD, and each family must determine, with the help of the appropriate professionals and services, how to best meet its own needs. Given the burdens of care, however, even small interventions may translate into improvements in the quality of life or confidence of the caregiver.

Daughters and sons as caregivers for their demented and non-demented elderly parents. A part of a population-based study carried out in Sweden

The study focuses on adult children (n = 81) having the main responsibility for parents with dementia (study group). They were compared with children (n = 102) of non-demented parents (reference group). The children were interviewed about burden experienced. The interviews also secured information about the children's co-operation with the informal and formal network and their willingness to remain as caregivers during the progression of the disease or ageing process. The results showed that the daughters reported feeling more affection in their caregiving role than the sons. About one third of the participants in the study could not get relief from someone else. Eighty-nine per cent of the children in the study group and 76% of the children in the reference group were not willing to care for their parents in the family home during the progression of the disease, even if they were employed as caregivers.

Measuring problem behaviors in dementia: developing a methodological agenda

As many as 90% of persons with dementing illness demonstrate problem behaviors that range from repetitive verbalizations, agitation, and wandering to verbal and physical aggression toward self and others. Reliable and accurate measurement of these behaviors is crucial for tracking illness progression; for monitoring the effects of pharmacologic and behavioral interventions; and for continued investigation into the correlates of caregiver stress, burden, and coping. However, there is no single, universally accepted measure or methodology for operationalizing problem behaviors, and variations in definition and measurement across studies complicate drawing meaningful conclusions about these behaviors. This article is an overview of five factors that have complicated accurate and dependable measurement of problem behaviors in dementia: the shifting domain of problem behaviors, slippage across research constructs, unexplored rater bias, scoring bias, and the absence of benchmarking studies. A methodological agenda is discussed for future investigations in this rapidly growing area of gerontological research.