The prevalence of autonomic symptoms in dementia and their association with physical activity, activities of daily living and quality of life

Digital Biomarkers for the Assessment of Non-Cognitive Symptoms in Patients with Dementia with Lewy Bodies: A Systematic Review

Background

Portable digital health technologies (DHTs) could help evaluate non-cognitive symptoms, but evidence to support their use in patients with dementia with Lewy bodies (DLB) is uncertain.

Objective

1) To describe portable or wearable DHTs used to obtain digital biomarkers in patients with DLB, 2) to assess the digital biomarkers' ability to evaluate non-cognitive symptoms, and 3) to assess the feasibility of applying digital biomarkers in patients with DLB.

Methods

We systematically searched databases MEDLINE, Embase, and Web of Science from inception through February 28, 2023. Studies assessing digital biomarkers obtained by portable or wearable DHTs and related to non-cognitive symptoms were eligible if including patients with DLB. The quality of studies was assessed using a modified check list based on the NIH Quality assessment tool for Observational Cohort and Cross-sectional Studies. A narrative synthesis of data was carried out.

Results

We screened 4,295 records and included 20 studies. Seventeen different DHTs were identified for assessment of most non-cognitive symptoms related to DLB. No thorough validation of digital biomarkers for measurement of non-cognitive symptoms in DLB was reported. Studies did not report on aspects of feasibility in a systematic way.

Conclusions

Knowledge about feasibility and validity of individual digital biomarkers remains extremely limited. Study heterogeneity is a barrier for establishing a broad evidence base for application of digital biomarkers in DLB. Researchers should conform to recommended standards for systematic evaluation of digital biomarkers.

Autonomic nervous system flexibility for understanding brain aging

A recent call was made for autonomic nervous system (ANS) measures as digital health markers for early detection of Alzheimer's disease and related dementia (AD/ADRD). Nevertheless, contradictory or inconclusive findings exist. To help advance understanding of ANS' role in dementia, we draw upon aging and dementia-related literature, and propose a framework that centers on the role of ANS flexibility to guide future work on application of ANS function to differentiating the degree and type of dementia-related brain pathologies. We first provide a brief review of literature within the past 10 years on ANS and dementia-related brain pathologies. Next, we present an ANS flexibility model, describing how the model can be applied to understand these brain pathologies, as well as differentiate or even be leveraged to modify typical brain aging and dementia. Lastly, we briefly discuss the implication of the model for understanding resilience and vulnerability to dementia-related outcomes.

Autonomic dysfunction in dementia with Lewy bodies: Focusing on cardiovascular and respiratory dysfunction

Dementia with Lewy bodies (DLB) is the second most common cause of dementia after Alzheimer's disease. The disease is characterized by many Lewy bodies appearing in the patient's cerebrum. DLB frequently presents with a variety of autonomic symptoms from the early or prodromal stages of the disease, and these are listed as supportive features in the diagnostic criteria. As several useful assessment methods for evaluating autonomic function in DLB have been reported, this review will focus on cardiovascular and respiratory dysfunction and its assessments. Cardiovascular disorders, such as orthostatic hypotension and abnormal heart rate variability, have been reported in DLB patients. Decreased myocardial uptake by metaiodobenzylguanidine myocardial scintigraphy has been added as an indicative biomarker for DLB in the 2017 revision of the diagnostic criteria. We have reported reduced ventilatory response to hypercapnia, abnormal respiratory rhythm, and high frequency of sleep-disordered breathing as abnormalities of the respiratory regulatory system associated with DLB. Since autonomic dysfunction is highly prevalent in DLB from the early or prodromal phase of the disease and is associated with reduced activities of daily living and quality of life, the evaluation of autonomic dysfunction is also useful in the differential diagnosis of DLB from Alzheimer's disease. There are fewer studies on the respiratory regulatory system than on the cardiovascular system, thus further research is needed to explore its role in DLB.

Impact of dysautonomic symptom burden on the quality of life in Neuromyelitis optica spectrum disorder patients

BACKGROUND

This study aimed to investigate the clinical risk factors of dysautonomic symptom burden in neuromyelitis optica spectrum disorder (NMOSD) and its impact on patients' quality of life.

METHODS

A total of 63 NMOSD patients and healthy controls were enrolled. All participants completed the Composite Autonomic Symptom Score 31 (COMPASS-31) to screen for symptoms of autonomic dysfunction. A comprehensive clinical evaluation was performed on NMOSD patients, such as disease characteristics and composite evaluations of life status, including quality of life, anxiety/depression, sleep, and fatigue. Correlated factors of dysautonomic symptoms and quality of life were analyzed.

RESULTS

The score of COMPASS-31 in the NMOSD group was 17.2 ± 10.3, significantly higher than that in healthy controls (P = 0.002). In NMOSD patients, the higher COMPASS-31 score was correlated with more attacks (r = 0.49, P < 0.001), longer disease duration (r = 0.52, P < 0.001), severer disability (r = 0.50, P < 0.001), more thoracic cord lesions (r = 0.29, P = 0.02), more total spinal cord lesions (r = 0.35, P = 0.005), severer anxiety (r = 0.55, P < 0.001), severer depression (r = 0.48, P < 0.001), severer sleep disturbances (r = 0.59, P < 0.001), and severer fatigue (r = 0.56, P < 0.001). The disability, total spinal cord lesions, and fatigue were revealed to be independently associated factors. Further analysis revealed that the COMPASS-31 score was independently correlated with scores of all the domains of patients' quality of life scale (P < 0.05).

CONCLUSIONS

Dysautonomic symptom burden is correlated with decreased quality of life and certain clinical characteristics such as disability, the burden of spinal cord lesions, and fatigue in NMOSD patients. Investigation and proper management of autonomic dysfunction may help to improve the quality of life in patients with NMOSD.

Effectiveness of physical exercise at improving functional capacity in older adults living with Alzheimer's disease: a systematic review of randomized controlled trials

PURPOSE

To investigate the effects of physical exercise at improving functional capacity in older adults living with Alzheimer's disease (AD).

METHODS

Medline, Embase, Web of Science, The Cochrane Library, Lilacs, and PEDro were searched from inception until January 2021. Randomized controlled trials (RCTs) that reported functional capacity outcomes were included. The evidence was assessed using the GRADE approach.

RESULTS

Thirteen RCTs were included, involving 811 older adults living with AD. Multimodal exercise (ME), aerobic exercise (AE), and resistance exercise (RE) were used. The interventions were mainly supervised by caregivers. The evidence was low and with effect for activities of daily living (ADLs), moderate and with no effect for mobility and very low and with no effect for muscle strength, postural balance and flexibility after treatment with ME, moderate and with no effect for cardiorespiratory function and ADLs after treatment with AE. It was not possible to synthesize any type of evidence for RE.

CONCLUSIONS

Multimodal exercise promotes improvements in functional capacity (ADLs). Therefore, the practice of physical exercise can be recommended for older adults living with AD. The involvement of the caregiver in the physical exercises should also be considered, as it could enhance the benefits of exercise for these older adults.Implications for rehabilitationHealthcare providers with clinical knowledge regarding physical exercise should promote, prescribe and support the daily practice of physical exercises for older adults living with Alzheimer's disease (AD).The involvement of caregivers in home-based physical exercise programs should be considered, as it could enhance the benefits of such programs for these older adults.It is important to consider the degree of cognitive impairment in older adults living with AD when outlining goals for the improvement in functional capacity through physical exercise.Multimodal exercise involving aerobic training, postural balance, muscle strengthening, and flexibility is capable of promoting an improvement in functional capacity (activities of daily living) for these older adults.

Assessment of clinical features and coexisting geriatric syndromes in newly diagnosed dementia with Lewy bodies: a retrospective study in a tertiary geriatrics setting in Turkey

PURPOSE

Identifying the associated clinical conditions in patients with newly diagnosed dementia with Lewy bodies (DLB) may contribute to the disease management. This study aimed to examine the clinical features and coexisting geriatric syndromes of patients with newly diagnosed DLB.

METHOD

This cross-sectional study included newly diagnosed DLB participants who were admitted to a tertiary geriatric outpatient clinic. Of the 857 patients with dementia, 116 DLB diagnoses were eligible for analysis. The core and supportive clinical features of DLB were recorded. Geriatric syndromes including polypharmacy, depression, insomnia, dependency, a history of delirium, falls, malnutrition, urinary incontinence, functional impairment, and living alone, were assessed and recorded at baseline.

RESULTS

The mean age was 79.0 ± 6.9 years, and 50.9% of the participants were female. The majority (63.8%) had mild dementia, 31.9% had moderate, and 4.3% had severe disease. Cognitive fluctuations (78.4%), visual hallucinations (77.6%), and Parkinsonism (73.3%) were the most common clinical features. Functional impairment (59.5%) and urinary incontinence (59.5%) were the leading geriatric syndromes, followed by polypharmacy (56.9%), depressive symptoms (54.7%), falls (52.6%), insomnia (49.1%), malnutrition (24.3%), and delirium (6.0%). Women had more functional impairment and depressive symptoms than men.

CONCLUSION

Although most patients had mild dementia, three-quarters of the DLB cohort had hallucinations, and nearly two-thirds were functionally impaired. The proportion of other serious health conditions also increased, indicating a high comorbidity and geriatric syndrome burden. Comprehensive geriatric assessment is strongly recommended for DLB patients from the time of diagnosis until death to reduce disability and comorbidities.

THE CLINICAL TRIAL REGISTRATION NUMBER

NCT05052450.

Frequency, Severity, and Duration of Autonomic Symptoms in Patients of Prodromal Dementia with Lewy Bodies

Background: Autonomic dysfunction is supportive clinical feature for diagnosis of prodromal dementia with Lewy bodies (DLB). Objective: To compare the features of autonomic symptoms in patients with mild cognitive impairment (MCI) due to Lewy bodies (MCI-LB) and Alzheimer’s disease (MCI-AD). Methods: Autonomic symptoms were evaluated in the MCI-LB and MCI-AD patients using the Scales for Outcomes in Parkinson’s disease for autonomic symptoms (SCOPA-AUT). Results: Thirty patients with MCI-LB and 90 patients with MCI-AD were recruited. The frequency of autonomic dysfunction was higher in patients with MCI-LB compared to the MCI-AD patients (80% versus 54.4%, p = 0.013) and the gastrointestinal symptoms were predominant (73.3% versus 35.6%, p <  0.001). Salivation, constipation, incontinence, incomplete emptying, lightheadedness when standing up or standing for some times, diurnal or nocturnal hyperhidrosis, and sexual dysfunction were more severe and protracted in the MCI-LB group compared to the MCI-AD group. Conclusion: The MCI-LB patients showed higher frequency and severity, as well as longer duration of autonomic symptoms compared to the MCI-AD group. These symptoms can facilitate early diagnosis of patients with DLB.

Assessment of autonomic symptoms may assist with early identification of mild cognitive impairment with Lewy bodies

OBJECTIVES

Autonomic symptoms are a common feature of the synucleinopathies, and may be a distinguishing feature of prodromal Lewy body disease. We aimed to assess whether the cognitive prodrome of dementia with Lewy bodies, mild cognitive impairment (MCI) with Lewy bodies (MCI-LB), would have more severe reported autonomic symptoms than cognitively healthy older adults, with MCI due to Alzheimer's disease (MCI-AD) also included for comparison. We also aimed to assess the utility of an autonomic symptom scale in differentiating MCI-LB from MCI-AD.

METHODS

Ninety-three individuals with MCI and 33 healthy controls were assessed with the Composite Autonomic Symptom Score 31-item scale (COMPASS). Mild cognitive impairment patients also underwent detailed clinical assessment and differential classification of MCI-AD or MCI-LB according to current consensus criteria. Differences in overall COMPASS score and individual symptom sub-scales were assessed, controlling for age.

RESULTS

Age-adjusted severity of overall autonomic symptomatology was greater in MCI-LB (Ratio = 2.01, 95% CI: 1.37-2.96), with higher orthostatic intolerance and urinary symptom severity than controls, and greater risk of gastrointestinal and secretomotor symptoms. MCI-AD did not have significantly higher autonomic symptom severity than controls overall. A cut-off of 4/5 on the COMPASS was sensitive to MCI-LB (92%) but not specific to this (42% specificity vs. MCI-AD and 52% vs. healthy controls).

CONCLUSIONS

Mild cognitive impairment with Lewy bodies had greater autonomic symptom severity than normal ageing and MCI-AD, but such autonomic symptoms are not a specific finding. The COMPASS-31 may therefore have value as a sensitive screening test for early-stage Lewy body disease.

Autonomic symptoms are predictive of dementia with Lewy bodies

INTRODUCTION

Autonomic symptoms are common in patients with dementia with Lewy bodies (DLB). Although autonomic dysfunction is considered as one of the primary early markers in patients with DLB, there are few studies that examine the timing of the onset of autonomic symptoms in these patients. The purpose of the current study was to evaluate the time of onset of autonomic symptoms in patients with DLB using a questionnaire.

METHODS

Autonomic symptoms were evaluated in patients with DLB using the Scales for Outcomes in Parkinson's disease - autonomic (SCOPA-Aut) questionnaire. Time of the onset of autonomic symptoms of patients with DLB was also assessed relative to that of memory loss.

RESULTS

A total of 106 patients with DLB were included. The most frequent symptom of dysautonomia in patients with DLB was constipation (60.4%), followed by orthostatic dizziness (33%), urinary frequency (30.2%), and daytime hyperhidrosis (22.6%). The gastrointestinal system was the most prominent system of autonomic dysfunction in patients with DLB. Orthostatic dizziness, daytime hyperhidrosis, and constipation all preceded the onset of memory loss by 0.2 ± 4.9, 3.3 ± 8.6, and 3.7 ± 9.2 years, respectively, while urinary incontinence occurred 1.7 ± 1.5 years following the onset of memory loss.

CONCLUSION

Many autonomic symptoms precede the onset of memory loss in patients with DLB, especially constipation and daytime hyperhidrosis. These symptoms can facilitate an early diagnosis of patients with DLB.

Autonomic Symptoms in Older Adults Are Common and Associated With Health-Related Quality of Life

Background: Autonomic symptoms are common in older adults, and a large body of literature focusing on age-related diseases shows that autonomic symptoms in these diseases constrain Health-Related Quality of Life (HRQoL). To our best knowledge, the association between autonomic symptoms in older adults, independent of specific diseases, and HRQoL has not yet been assessed. Aim: To assess the frequency and the effect of autonomic symptoms in general, as well as orthostatic intolerance, vasomotor, secretomotor, gastrointestinal, bladder, and pupillomotor symptoms, on HRQoL in older adults. Methods: Cross-sectional data of the fourth visit of the Tübinger evaluation of Risk factors for Early detection of Neurodegeneration (TREND) study were included. Autonomic symptoms, as assessed with the Composite Autonomic Symptom Score 31 (COMPASS 31), were quantified and compared with HRQoL, as assessed with the EuroQol five-level version (EQ-5D-5L). Statistical analyses included Spearman's rank correlation and multiple linear regression analysis. Results: The analysis included 928 participants with a median of 68 years; 47% were women. Of those, 85% reported at least one autonomic symptom. Gastrointestinal and secretomotor symptoms were most common. The COMPASS 31 total score and all subdomains were significantly associated with reduced HRQoL. Among the subdomains, the strongest correlations with HRQoL were found for gastrointestinal and bladder symptoms. Overall, autonomic symptoms alone explained 20% of the variance of HRQoL; when depressive mood was added, the model explained 32%. Conclusion: Autonomic symptoms are associated with HRQoL and depressive symptoms in older adults.

Exploring the experiences of living with Lewy body dementia: An integrative review

AIM

Lewy body dementia is a common neurodegenerative dementia with unique challenges in managing day-to-day life. A more in-depth multifaceted picture of the Lewy body dementia lived experience will enable identification of best practice and future research direction. The review aim was to explore experiences of people living with Lewy body dementia and their family carers.

DESIGN

Integrative review method informed by Whittemore and Knafl, supported by the information retrieval framework PALETTE. A convergent integrated approach enabled synthesis of key findings and theme identification.

DATA SOURCES

Medline, CINAHL, PsycINFO, AMED, and ALOIS databases were systematically searched to find studies published between 1995 and 2020.

REVIEW METHODS

Twenty-six articles from twenty studies were synthesized (from 1583 retrieved). Quality and relevance were appraised using the Mixed-Methods Appraisal Tool and Gough's 'Weight of Evidence' framework. Data management was supported by ATLAS.ti 8 and COVIDENCE software.

RESULTS

Four themes were identified: living with an uncertain diagnosis and prognosis; fear of the now - worry for the future; living with behavioural and psychiatric symptoms; and maintaining a social and emotional life. People reported difficulty finding information and support around diagnosis, disease progression and managing complex symptoms. The result is increased caregiver burden, grief and stress and reduced quality of life.

CONCLUSION

Delayed diagnosis and complex symptom burden means people are not getting the timely support and information they need to live and die well. Current evidence is largely quantitative, with a focus on family caregiver burden and unmet need. The challenge remains in how to capture a more holistic picture of the lived experience for people living with Lewy body dementia and those who care for them.

IMPACT

This review highlighted current knowledge and identified gaps in exploring the lived experience for people with Lewy body dementia and their families.

The Role of Heart Rate Variability in the Future of Remote Digital Biomarkers

Heart rate variability (HRV) offers insights into humoral, neural and neurovisceral processes in health and disorders of brain, body and behavior but has yet to be fully potentiated in the digital age. Remote measurement technologies (RMTs), such as, smartphones, wearable sensors or home-based devices, can passively capture HRV as a nested parameter of neurovisceral integration and health during everyday life, providing insights across different contexts, such as activities of daily living, therapeutic interventions and behavioral tasks, to compliment ongoing clinical care. Many RMTs measure HRV, even consumer wearables and smartphones, which can be deployed as wearable sensors or digital cameras using photoplethysmography. RMTs that measure HRV provide the opportunity to identify digital biomarkers indicative of changes in health or disease status in disorders where neurovisceral processes are compromised. RMT-based HRV therefore has potential as an adjunct digital biomarker in neurovisceral digital phenotyping that can add continuously updated, objective and relevant data to existing clinical methodologies, aiding the evolution of current "diagnose and treat" care models to a more proactive and holistic approach that pairs established markers with advances in remote digital technology.

Increasing Physical Activity in Persons With Dementia: A Randomized Controlled Trial

This study investigated the effectivity and sustainability of a physical activity (PA) promotion and motor training programs and analyzed predictors for PA changes in persons with dementia. A total of 122 participants with mild-to-moderate dementia were randomized to the intervention program designed for persons with dementia (intervention group) or a motor placebo activity (control group). The primary outcome was the Physical Activity Questionnaire for the Elderly assessed at the baseline, after the 3-month intervention, and at a 3-month follow-up. The PA promotion program significantly increased PA in the intervention group compared with the control group during the training intervention phase. Both groups showed an increase in habitual PA when intervention-induced activities were excluded. PA was sustainably increased in both groups at follow-up. Low baseline PA was predictive for increased PA after the intervention and low baseline PA, high motor performance, and low comorbidity for increased PA at follow-up.

End Stage Clinical Features and Cause of Death of Behavioral Variant Frontotemporal Dementia and Young-Onset Alzheimer's Disease

BACKGROUND

Limited literature exists regarding the clinical features of end stage behavioral variant frontotemporal dementia (bvFTD). This data is indispensable to inform and prepare family members as well as professional caregivers for the expected disease course and to anticipate with drug-based and non-pharmacological treatment strategies.

OBJECTIVE

The aim of the present study was to describe end stage bvFTD in a broad explorative manner and to subsequently evaluate similarities and dissimilarities with the end stage of the most prevalent form of young-onset dementia, Alzheimer's disease (yoAD).

METHODS

We analyzed medical files on patients, using a mixed model of qualitative and quantitative approaches. Included were previously deceased patients with probable bvFTD and probable yoAD. End stage was defined as the last 6 months prior to death. Primary outcome measures comprised somatic, neurological, and psychiatric symptoms and the secondary outcome measure was cause of death.

RESULTS

Out of 89 patients, a total of 30 patients were included (bvFTD; n = 12, yoAD; n = 18). Overall, the end stages of bvFTD and yoAD were characterized by a broad spectrum of clinical symptoms including severe autonomic dysfunction and an increased muscle tone. Patients with bvFTD displayed more mutism compared with yoAD while compulsiveness was only present in bvFTD.

CONCLUSION

Our study describes the full clinical spectrum of end stage bvFTD and yoAD. In this study, symptoms extend far beyond the initial behavioral and cognitive features. By taking both somatic, psychiatric, and neurological features into account, family members and professional caregivers may anticipate (non) pharmacological treatment.

Small vessel disease pathological changes in neurodegenerative and vascular dementias concomitant with autonomic dysfunction

We performed a clinicopathological study to assess the burden of small vessel disease (SVD) type of pathological changes in elderly demented subjects, who had clinical evidence of autonomic dysfunction, either carotid sinus hypersensitivity or orthostatic hypotension or both or had exhibited unexpected repeated falls. Clinical and neuropathological diagnoses in 112 demented subjects comprised dementia with Lewy bodies (DLB), Parkinson's disease with dementia (PDD), Alzheimer's disease (AD), Mixed dementia (mostly AD-DLB) and vascular dementia (VaD). Of these, 12 DLB subjects had no recorded unexpected falls in life and therefore no evidence of concomitant autonomic dysfunction. A further 17 subjects were assessed as aging controls without significant pathology or signs of autonomic dysfunction. We quantified brain vascular pathological changes and determined severities of neurodegenerative lesions including α-synuclein pathology. We found moderate-severe vascular changes and high-vascular pathology scores (P < 0.01) in all neurodegenerative dementias and as expected in VaD compared to similar age controls. Arteriolosclerosis, perivascular spacing and microinfarcts were frequent in the basal ganglia and frontal white matter (WM) across all dementias, whereas small infarcts (<5 mm) were restricted to VaD. In a sub-set of demented subjects, we found that vascular pathology scores were correlated with WM hyperintensity volumes determined by MRI in life (P < 0.02). Sclerotic index values were increased by ~50% in both the WM and neocortex in all dementias compared to similar age controls. We found no evidence for increased α-synuclein deposition in subjects with autonomic dysfunction. Our findings suggest greater SVD pathological changes occur in the elderly diagnosed with neurodegenerative dementias including DLB and who develop autonomic dysfunction. SVD changes may not necessarily manifest in clinically overt symptoms but they likely confound motor or cognitive dysfunction. We propose dysautonomia promotes chronic cerebral hypoperfusion to impact upon aging-related neurodegenerative disorders and characterize their end-stage clinical syndromes.

Diagnosis and Management of Autonomic Dysfunction in Dementia Syndromes

PURPOSE OF REVIEW

Autonomic dysfunction is common in dementia, particularly in the Lewy body dementias. This review considers the evidence for autonomic dysfunction in dementia, common symptoms and potential management options.

RECENT FINDINGS

Autonomic dysfunction has been shown in Alzheimer's disease and Lewy body dementias. Common symptoms include orthostatic dizziness, syncope, falls, urinary tract symptoms and constipation. Non-pharmacological management of orthostatic hypotension should include bolus water drinking. Pharmacological management may include the use of midodrine or droxidopa although the latter is not available in Europe. Atomoxetine is a noradrenaline reuptake inhibitor which may be useful if further clinical trials become available. Management of constipation may include the use o f probiotics, osmotic laxatives such as macrogol and chloride type 2 channel activators such as lubiprostone. Management of urinary tract symptoms may include the use of mirabegron. There is a dearth of clinical trials for autonomic dysfunction in dementia and most of the evidence is imputed from trials in Parkinson's disease. However, pragmatic recommendations may be made. There is a need for controlled clinical trials in people with dementia.

Dementia with Lewy bodies: Challenges in the diagnosis and management

OBJECTIVE

Dementia with Lewy bodies is the second most common form of neurodegenerative dementia in older age yet is often under-recognised and misdiagnosed. This review aims to provide an overview of the clinical features of dementia with Lewy bodies, discussing the frequent challenges clinicians experience in diagnosing dementia with Lewy bodies, and outlines a practical approach to the clinical management, particularly in the Australian setting.

METHODS

This paper is a narrative review and a semi-structured database (PubMed and MEDLINE) search strategy was implemented. Articles were screened and clinically relevant studies were selected for inclusion.

RESULTS

Dementia with Lewy bodies is clinically characterised by complex visual hallucinations, spontaneous motor parkinsonism, prominent cognitive fluctuations and rapid eye movement sleep behaviour disorder. Neuropsychiatric features and autonomic dysfunction are also common. The new diagnostic criteria and specific diagnostic biomarkers help to improve detection rates and diagnostic accuracy, as well as guide appropriate management. Clinical management of dementia with Lewy bodies is challenging and requires an individualised multidisciplinary approach with specialist input.

CONCLUSION

Dementia with Lewy bodies is a common form of dementia. It often presents as a diagnostic challenge to clinicians, particularly at early stages of disease, and in patients with mixed neuropathological changes, which occur in over 50% of people with dementia with Lewy bodies. Prompt diagnosis and comprehensive treatment strategies are important in improving patients' care.

Dementia subtype and living well: results from the Improving the experience of Dementia and Enhancing Active Life (IDEAL) study

BACKGROUND

The heterogeneity of symptoms across dementia subtypes has important implications for clinical practice and dementia research. Variation in subtypes and associated symptoms may influence the capability to live well for people with dementia and carers. The aim of this study is to investigate the potential impact of dementia subtypes on the capability to live well for both people with dementia and their carers.

METHODS

The analysis was based on the 1283 dyads of community-dwelling people with dementia and carers in the Improving the experience of Dementia and Enhancing Active Life (IDEAL) project, a large cohort study in Great Britain. Capability to live well was defined using three measures: quality of life, life satisfaction and wellbeing. Structural equation modelling was used to investigate capability to live well in seven dementia subtypes: Alzheimer's disease (AD), Vascular dementia (VaD), mixed AD/VaD, frontotemporal dementia (FTD), Parkinson's disease dementia (PDD), Lewy body dementia (LBD) and unspecified/other, accounting for dyadic data structure and adjusting for age and sex, type of relationship between person with dementia and their carer and the number of chronic conditions.

RESULTS

The major subtypes in this study population were AD (56%), VaD (11%) and mixed AD/VaD (21%). Compared to participants with AD, people with non-AD subtypes generally reported a lower capability to live well. Carers for people with PDD (- 1.71; 95% confidence interval (CI) - 3.24, - 0.18) and LBD (- 2.29; 95% CI - 3.84, - 0.75) also reported a lower capability to live well than carers for people with AD. After adjusting for demographic factors and comorbidity, PDD (- 4.28; 95% CI - 5.65, - 2.91) and LBD (- 3.76; 95% CI - 5.14, - 2.39) continued to have the strongest impact on both people with dementia and their carers.

CONCLUSIONS

This study suggests a variation in capability to live well across dementia subtypes. It is important for care providers to consider different needs across subtypes. Health professionals who provide post-diagnostic support may need to pay more attention to the complex needs of people living with PDD and LBD and their carers.

Quality of Life in Patients with Dementia with Lewy Bodies

Dementia with Lewy bodies (DLB) is a complex, multisymptom disorder. When making decisions regarding the treatment of DLB, the patient's quality of life (QoL) should always be the main consideration. To our knowledge, this is the first review article focusing on the QoL in DLB patients. We searched the PubMed database using the keywords "quality of life" and "dementia with Lewy bodies." Previously, no specific instrument had been developed for assessing the QoL in DLB patients. Patients with DLB have a decreased QoL compared to patients with Alzheimer's disease, which is reportedly caused by several factors including level of independence in instrumental activities of daily living, whether the patient is living with the caregiver, apathy, delusion, and dysautonomia. The direct effect of visual hallucination, sleep, and movement disorders on the QoL in DLB patients has not been previously studied. The role of cognitive function on the QoL is still controversial. In a randomized controlled study, memantine may improve the QoL in PDD or DLB patients. We concluded that it is important to develop a specific instrument to assess the QoL in DLB patients. Furthermore, there is an urgent need for large clinical trials to identify factors associated with the QoL and how they can be managed.

Relationship between the severity of cerebral white matter hyperintensities and sympathetic nervous activity in older adults

AIM

White matter hyperintensities (WMH), visualized on brain magnetic resonance imaging, represent an abnormality related to the development of geriatric syndromes. Recently, it has been found that low sympathetic nervous activity might be associated with physical and cognitive dysfunction in older adults. Therefore, we investigated the relationship between the severity of cerebral WMH and sympathetic nervous activity, measured by the heart rate variability.

METHODS

We carried out a cross-sectional study of 39 older patients. Holter recording was carried out for 30 min. From the RR intervals on the electrocardiogram, the standard deviation of the normal-to-normal intervals, the standard deviation of all normal-to-normal intervals in all the five segments of the entire recording, low frequency (LF), high frequency (HF) and LF/HF were calculated. In regard to the WMH, periventricular hyperintensities and deep white matter hyperintensities (DWMH) were rated according to the Fazekas classification. The WMH were also rated semiquantitatively according to the methods developed by Junque (periventricular hyperintensities) and de Groot (DWMH).

RESULTS

The LF/HF showed significant negative correlations with the total and regional periventricular hyperintensities, as well as DWMH. Multiple regression analysis showed that the negative associations remained significant between the LF/HF and DWMH (total, temporal, occipital). Furthermore, fall risk index significantly correlated with the LF/HF, total and the occipital DWMH.

CONCLUSIONS

The severity of the DWMH was associated with the LF/HF and the fall risk, one of the important geriatric syndromes, suggesting that WMH, sympathetic nervous dysfunction and geriatric syndrome are interrelated to each other. Geriatr Gerontol Int 2018; 18: 569-575.

Montessori-Based Activities Among Persons with Late-Stage Dementia: Evaluation of Mental and Behavioral Health Outcomes

OBJECTIVES

Literature regarding Montessori-based activities with older adults with dementia is fairly common with early stages of dementia. Conversely, research on said activities with individuals experiencing late-stage dementia is limited because of logistical difficulties in sampling and data collection. Given the need to understand risks and benefits of treatments for individuals with late-stage dementia, specifically regarding their mental and behavioral health, this study sought to evaluate the effects of a Montessori-based activity program implemented in a long-term care facility.

METHOD

Utilizing an interrupted time series design, trained staff completed observation-based measures for 43 residents with late-stage dementia at three intervals over six months. Empirical measures assessed mental health (anxiety, psychological well-being, quality of life) and behavioral health (problem behaviors, social engagement, capacity for activities of daily living).

RESULTS

Group differences were observed via repeated measures ANOVA and paired-samples t-tests. The aggregate, longitudinal results-from baseline to final data interval-for the psychological and behavioral health measures were as follows: problem behaviors diminished though not significantly; social engagement decreased significantly; capacities for activities of daily living decreased significantly; quality of life increased slightly but not significantly; anxiety decreased slightly but not significantly; and psychological well-being significantly decreased.

CONCLUSION

Improvements observed for quality of life and problem behaviors may yield promise for Montessori-based activities and related health care practices. The rapid physiological and cognitive deterioration from late-stage dementia should be considered when interpreting these results.

Autonomic Dysfunction in Patients with Mild to Moderate Alzheimer's Disease

BACKGROUND

Autonomic function has received little attention in Alzheimer's disease (AD). AD pathology has an impact on brain regions which are important for central autonomic control, but it is unclear if AD is associated with disturbance of autonomic function.

OBJECTIVE

To investigate autonomic function using standardized techniques in patients with AD and healthy age-matched controls.

METHOD

Thirty-three patients with mild to moderate AD and 30 age- and gender-matched healthy controls, without symptoms of autonomic dysfunction, underwent standardized autonomic testing with deep breathing, Valsalva maneuver, head-up tilt, and isometric handgrip test. Brachial pressure curve and electrocardiogram were recorded for off-line analysis of blood pressure and beat-to-beat heart rate (HR).

RESULTS

AD patients had impaired blood pressure responses to Vasalva maneuver (p < 0.0001) and HR response to isometric contraction (p = 0.0001). A modified composite autonomic scoring scale showed greater degree of autonomic impairment in patients compared to controls (patient: 2.1 ± 1.6; controls: 0.9 ± 1.1, p = 0.001). HR response to deep breathing and Valsalva ratio were similar in the two groups.

CONCLUSION

We identified autonomic impairment ranging from mild to severe in patients with mild to moderate AD, who did not report autonomic symptoms. Autonomic impairment was mainly related to impairment of sympathetic function and evident by impaired blood pressure response to the Vasalva maneuver. The clinical implications of this finding are that AD may be associated with autonomic disturbances, but patients with AD may rarely report symptoms of autonomic dysfunction. Future research should systematically evaluate symptoms of autonomic function and characterize risk factors associated with autonomic dysfunction.

Older Adults with Dementia Are Sedentary for Most of the Day

PURPOSE

Self-reported data suggest that older adults with dementia are inactive. The purpose of the present study was to objectively assess the physical activity (PA) levels of community-dwelling and institutionalized ambulatory patients with dementia, and to compare with the PA levels of cognitive healthy older adults.

METHODS

We used actigraphy to assess the PA levels in institutionalized (n = 83, age: 83.0 ± 7.6, Mini-Mental-State Examination (MMSE): 15.5 ± 6.5) and community-dwelling dementia patients (n = 37, age: 77.3 ± 5.6, MMSE-score: 20.8 ± 4.8), and healthy older adults (n = 26, age: 79.5 ± 5.6, MMSE-score: 28.2 ± 1.6). We characterized PA levels based on the raw data and classified <100 counts/min as sedentary behavior.

RESULTS

Institutionalized dementia patients had the lowest daily PA levels (1.69 ± 1.33 counts/day), spent 72.1% of the day sedentary, and were most active between 8:00 and 9:00 am. Institutionalized vs. community-dwelling dementia patients had 23.5% lower daily PA levels (difference M = 0.52, p = .004) and spent 9.3% longer in sedentariness (difference M = 1.47, p = .032). Community-dwelling dementia patients spent 66.0% of the day sedentary and were most active between 9:00 to 10:00 am with a second peak between 14:00 to 15:00. Community-dwelling dementia patients vs healthy older adults' daily PA levels and sedentary time were 21.6% lower and 8.9% longer, respectively (difference M = 0.61, p = .007; difference M = 1.29, p = .078).

CONCLUSIONS

Institutionalized and community-dwelling dementia patients are sedentary for most of the day and the little PA they perform is of lower intensity compared to their healthy peers. Their highest PA peak is when they get out of bed in the morning. In addition, it seems that institutionalized living is associated with lower PA levels in dementia patients. These are the first results that objectively characterize institutionalized as well as community-dwelling dementia patients' PA levels and confirm that dementia patients are inactive.

Patterns of Chinese medicine use in prescriptions for treating Alzheimer's disease in Taiwan

BACKGROUND

Certain Chinese medicine (CM) herbs and acupuncture may protect against Alzheimer's disease (AD). However, there is a lack of research regarding the use of CM in patients with AD. The aim of this study was to investigate CM usage patterns in patients with AD, and identify the Chinese herbal formulae most commonly used for AD.

METHODS

This retrospective, nationwide, population-based cohort study was conducted using a randomly sampled cohort of one million patients, selected from the National Health Insurance Research Database between 1997 and 2008 in Taiwan. CM use and the top ten most frequently prescribed formulae for treating AD were assessed, including average formulae dose and frequency of prescriptions. Demographic characteristics, including sex, age and insurance level were examined, together with geographic location. Existing medical conditions with the behavioral and psychological symptoms of dementia, and medications associated with CM were also examined. Factors associated with CM use were analyzed by multiple logistic regressions.

RESULTS

The cohort included 1137 newly diagnosed AD patients, who were given conventional treatment for AD between 1997 and 2008. Among them, 78.2 % also used CM treatments, including Chinese herbal remedies, acupuncture and massage manipulation. Female patients (aOR 1.57 with 95 % CI 1.16-2.13) and those living in urban areas (aOR 3.00 with 95 % CI 1.83-4.90 in the middle of Taiwan) were more likely to use CM. After adjusting for demographic factors, AD patients suffering from the behavioral and psychological symptoms of dementia were more likely to seek CM treatment than those with no symptoms (aOR 2.26 with 95 % CI 1.48-3.43 in patients suffering more than three symptoms). Bu-Zhong-Yi-Qi-Tang and Ji-Sheng-Shen-Qi-Wan were the two formulae most frequently prescribed by CM practitioners for treating AD.

CONCLUSION

Most people with AD who consumed herbal products used supplement qi, nourish the blood, and quiet the heart spirit therapy as complementary medicines to relieve AD-related symptoms, in addition to using standard anti-AD treatments.

IMPROVING THE CLINICAL DETECTION OF LEWY BODY DEMENTIA WITH THE LEWY BODY COMPOSITE RISK SCORE

INTRODUCTION

Dementia with Lewy bodies (DLB) is a challenge to diagnose, particularly outside of expert centers with long delays in diagnosis leading to significant burden to patients and caregivers. While consensus criteria have excellent specificity, there is no standardized way to assess symptoms reducing sensitivity. We developed the Lewy Body Composite Risk Score (LBCRS) from autopsy-verified cases to improve the ability to detect DLB in clinic and research populations.

METHODS

The LBCRS was tested in a consecutive series of 256 patients compared with the Clinical Dementia Rating and gold standard measures of cognition, motor symptoms, function, and behavior. Psychometric properties including floor and ceiling effects; concurrent, construct, and known-groups validity, and internal consistency of the LBCRS were determined. Receiver operator characteristic (ROC) curves assessed the ability of LBCRS to differentiate: (a) DLB from Alzheimer's disease (AD); (b) DLB from all dementia, and (c) Mild cognitive impairment (MCI) due to DLB from MCI due to AD. The LBCRS was completed independent of the clinical evaluation.

RESULTS

Mean LBCRS scores were significantly different between DLB and AD (6.1±2.0 vs. 2.4±1.3, p<.001) and between MCI-DLB vs MCI-AD (3.2±0.9 vs. 1.0±0.8, p<.001). The LBCRS was able to discriminate DLB from other causes of dementia. Using a cut-off score of 3, areas under ROC for DLB vs. AD = 0.93 (0.89-0.98), and for MCI-DLB vs. MCI-AD = 0.96 (0.91-1.0).

DISCUSSION

The LBCRS increases diagnostic probability that Lewy body pathology is contributing to the dementia syndrome and should improve clinical detection and enrollment for clinical trials.

Donepezil for dementia with Lewy bodies: a randomized, placebo-controlled, confirmatory phase III trial

Introduction

The efficacy of a cholinesterase inhibitor, donepezil, in patients with dementia with Lewy bodies (DLB) was investigated to confirm the superiority over placebo in the 12-week, double-blind phase of this phase III study.

Methods

Patients with probable DLB (n = 142) were randomly assigned to placebo or to 5 mg or 10 mg of donepezil administered once daily for 12 weeks. The co–primary endpoints were changes in cognitive function assessed using the Mini-Mental State Examination (MMSE) and behavioral and neuropsychiatric symptoms using the Neuropsychiatric Inventory (NPI-2: hallucinations and fluctuations). The superiority of each active group over placebo was determined with simultaneous statistical significance in both endpoints. Safety evaluations included adverse events (AEs) and the unified Parkinson's disease rating scale (UPDRS) part III.

Results

The predefined superiority of donepezil to the placebo was not confirmed in either active group in the primary analysis. MMSE score significantly improved compared to placebo in the 10 mg group (10 mg: 2.2 ± 0.4, placebo: 0.6 ± 0.5 (mean ± standard error); P = 0.016). The change in MMSE score in the 5 mg group was not significant (1.4 ± 0.5 (mean ± standard error); P = 0.232). Although NPI-2 improved compared to baseline in the active groups, the differences from placebo were not significant. Most AEs were mild or moderate. Although the incidence of parkinsonism was slightly higher in the 10 mg group, the change in the UPDRS score was minimal and without a significant difference from the placebo group.

Conclusions

The co–primary endpoints were not achieved in this trial. However, significant improvement in MMSE score was demonstrated with 10 mg, but not 5 mg, of donepezil. The evaluation of psychiatric symptoms might be affected by advanced education and instructions given to caregivers. Overall, donepezil was well tolerated in patients with DLB. With careful attention on gastrointestinal or parkinsonian symptoms, patients with DLB can safely benefit from treatment with donepezil.

Trial registration

ClinicalTrials.gov Identifier: NCT01278407 (trial registration date: 14 January 2011)

Electronic supplementary material

The online version of this article (doi:10.1186/s13195-014-0083-0) contains supplementary material, which is available to authorized users.

Lower urinary tract function in dementia with Lewy bodies (DLB)

OBJECTIVES

Dementia with Lewy bodies (DLB) is the second most common degenerative cause of dementia, whereas lower urinary tract (LUT) function in DLB patients has not been fully delineated. We investigated LUT function in DLB by clinical-urodynamic observations.

METHODS

We examined 32 patients with DLB (23 men, 9 women; aged 59-86 [mean, 75.9] years; disease duration, 0.2-17 [3.3] years). All patients underwent an electromyography-cystometry, and 21 patients underwent the sphincter motor unit potential analysis.

RESULTS

Ninety-one percent of patients had LUT symptoms: nighttime frequency (>8 times), 84%, and urinary incontinence (>1 per week), 50%. Detrusor overactivity was revealed in 87.1%, whereas postvoid residual was minimal. Neurogenic changes were shown in 50%.

CONCLUSION

LUT dysfunction is a common feature in DLB, attributable not only to dementia and immobility, but also to central and peripheral types of somato-autonomic dysfunction.

Persistence and Prognostic Implications of Orthostatic Hypotension in Older Individuals with Mild-to-Moderate Dementia

AIM

To study the course and prognostic implications of orthostatic hypotension (OH) in older individuals with mild-to-moderate dementia.

METHODS

Referrals to outpatient clinics specialising in old age psychiatry and geriatric medicine in the counties of Rogaland and Hordaland in western Norway with a first-time diagnosis of mild dementia were consecutively asked for inclusion. A total of 211 participants underwent a comprehensive baseline assessment with annual follow-ups. Patients with OH at both baseline and the 1-year follow-up were classified as having persistent OH. Outcome measures were the Mini-Mental State Examination (MMSE), the Clinical Dementia Rating sum of boxes (CDR-SB), and time to death.

RESULTS

From baseline to the 4-year follow-up, 30-45% of the participants had OH at each follow-up. In multivariable analysis, persistent OH was not significantly associated with either the longitudinal course of MMSE or CDR-SB scores or survival.

CONCLUSIONS

OH was moderately prevalent over 4 years in older individuals with mild dementia, and persistent OH did not predict either cognitive or functional decline or survival.

Lewy body dementia: the impact on patients and caregivers

Lewy body dementia (LBD) is the second most common neurodegenerative dementia in older adults, yet there remains a delay in diagnosis that limits healthcare providers’ ability to maximize therapeutic outcomes and enhance patient and caregiver quality of life. The impact of LBD on patients includes limiting the potential exposure to medications that may cause adverse outcomes, and addressing how the disease manifestations, such as autonomic features and behavior, affect quality of life. LBD impact on caregivers has been discussed to a greater degree in the literature, and there is clear evidence of caregiver burden and grief associated with disease manifestations. Other common caregiving concerns, such as access to care, prevention of hospitalization, managing behavior, and reviewing prognosis and nursing home placement, are important to comprehensively address the needs of patients with LBD and their caregivers.

Prevalence and Effectiveness of Laxative Use Among Elderly Residents in a Regional Hospital Affiliated Nursing Home in Hsinchu County

Background:

Long-term care residents are susceptible to constipation and one-half to three quarter of older nursing home residents receive laxatives regularly.

Objectives:

The purpose of this study was to evaluate the factors related to abnormal bowel function and explore the effectiveness of laxative treatment among the elderly residents of a nursing home.

Patients and Methods:

A total of 110 residents older than 65 years old was enrolled in this study. The following variables were gathered: age, gender, body mass index (BMI), length of stay, daily fluid intake, type of food, functional level, cognitive ability, physical therapy status, somatic and psychiatric diseases, number of medications, and medication use. The use and dosage of laxatives were recorded by means of Anatomical Therapeutic Chemical (ATC) classification system. Normal bowel function was defined as defecation frequency from three defecations per day to three defecations per week and stool consistency score of three to five on Bristol Stool Form Scale. A comparison between groups with normal and abnormal bowel function was drawn.

Results:

Low BMI, increased fluid intake, liquid food intake, poor functional level, poor cognition, and a history of stroke were significantly associated with altered bowel function (P < 0.05). The most frequently used laxatives were glycerol, senna glycoside, and magnesium oxide. There were significant differences in laxative regimens between residents with normal and altered bowel function; those with altered bowel function tended to take more laxatives than those with normal bowel function.

Conclusions:

This study suggested that treatment of constipation in the nursing home was unsatisfactory. To improve treatment outcomes in those susceptible to altered bowel function, a coordinated approach with involvement of physicians, nursing staff, and other professionals including dieticians and pharmacists seems necessary.

Donepezil for dementia with Lewy bodies: a randomized, placebo-controlled trial

Objective: Because cholinergic deficits are prominent in dementia with Lewy bodies (DLB), we investigated the effects of a cholinesterase inhibitor, donepezil, in such patients in a randomized, double-bilnd- placebo-controlled exploratory phase 2 trial.

Methods: One-hundred forty patients with DLB, recruited from 48 specialty centers in Japan, were randomly assigned to receive placebo or 3, 5, or 10mg of donepezil hydrochloride daily for 12 weeks (n = 35, 35, 33, and 37, respectively). Effects on cognitive function were assessed using the Mini-Mental State Examination (MMSE) and several domain-specific neuropsychological tests. Changes in behavior were evaluated using the Neuropsychiatric Inventory, caregiver burden using the Zarit Caregiver Burden Interview, and global function using the Clinician’s Interview-Based Impression of Change-plus Caregiver Input (CIBIC-plus). Safety measures included the Unified Parkinson’s Disease Rating Scale part III.

Results: Donepezil at 5 and 10mg/day was significantly superior to placebo on both the MMSE (5mg: mean difference, 3.8; 95% confidence interval [CI], 2.3-5.3; p < 0.001; 10 mg: mean difference, 2.4; 95% CI, 0.9-3.9; p = 0.001) and CIBIC-plus (p < 0.001 for each); 3mg/day was significantly superior to placebo on CIBIC-plus (p < 0.001), but not on the MMSE (p = 0.017). Significant improvements were found also in behavioral measures (p < 0.001) at 5 and 10mg/day and caregiver burden (p = 0.004) at 10 mg/day. The safety results were consistent with the known profile of donepezil and similar among groups.

Interpretation: Donepezil at 5 and 10mg/day produces significant cognitive, behavioral, and global improvements that last at least 12 weeks in DLB patients, reducing caregiver burden at the highest dose. Donepezil is safe and well tolerated.

Depression in mild dementia: associations with diagnosis, APOE genotype and clinical features

BACKGROUND

Depression is common in dementia, with important clinical implications. Few studies of depression in dementia with Lewy bodies are available, and the results are inconsistent.

OBJECTIVE

To examine the frequency of depression and its characteristics and correlates, in people with mild dementia.

METHODS

All referrals for patients with a first time diagnosis of dementia to geriatric and older psychiatry outpatient clinics in the counties of Rogaland and Hordaland in Western Norway from March 2005 to March 2007 were screened for the study. Participants and their caregivers underwent a comprehensive and standardised diagnostic and assessment procedure. The depression subitem of the neuropsychiatric inventory (NPId) and Montgomery and Åsberg depression rating scale (MADRS) were used to estimate depression. Cut-off scores for any depression were 0/1 (NPId) and 6/7 (MADRS), and for clinically significant depression 3/4 and 14/15, respectively.

RESULTS

Two hundered and twenty-three subjects with dementia participated, of whom 59 and 50% showed symptoms of depression assessed by NPI or MADRS, respectively, and 25 and 16% had clinically significant depression as measured by NPI and MADRS, respectively. Depression was more frequent in dementia with Lewy bodies (DLB) than in Alzheimer's disease (AD; p < 0.05). APOE genotype was available in 153 patients, and in AD, but not in DLB, a general linear model showed that the presence of APOEε4 allele was significantly associated with depression (F = 4.14; p = 0.045).

CONCLUSION

Depression is common even in mild dementia, and more common and severe in DLB compared to AD. Future studies should explore the longitudinal course of depression in DLB, and the neural underpinnings of depression in DLB.

Dementia with Lewy bodies is associated with higher scores on the Geriatric Depression Scale than is Alzheimer's disease

BACKGROUND

Several reports suggest a higher morbidity of depression in patients with dementia with Lewy bodies (DLB) than in patients with Alzheimer's disease (AD). However, these results have not been duplicated consistently. The psychiatric symptoms of dementia, including depression, are important for its diagnosis and management. Thus, the aim of the present study was to clarify the characteristics of the depressive symptoms in DLB compared with AD using the Geriatric Depression Scale (GDS).

METHODS

We examined the GDS score for 86 patients with probable DLB (based on the Consensus Criteria for the clinical diagnosis of DLB) and 86 patients with probable AD (based on criteria of the National Institute for Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association), who were matched according to age, sex, education, and Mini-Mental State Examination (MMSE) scores. We also examined correlations between GDS scores and age, sex, or MMSE scores in both groups. Correlations between GDS scores and metaiodobenzylguanidine (MIBG) scintigraphy were examined in patients with DLB. To characterize the GDS in DLB, its profile was examined using factor structures.

RESULTS

Scores for DLB patients were twice as high on the GDS as those for AD patients. There was no correlation between GDS score and age, sex, or MMSE scores in either group. Furthermore, there was no correlation between the results of MIBG scintigraphy and GDS scores in the DLB group. Using factor structures, the depression symptom profile of these diseases suggested that depression-specific symptoms, such as mood, worry, or future outlook, were more frequent in the DLB group than non-specific symptoms, such as lack of energy, decreased concentration, or apathy.

CONCLUSIONS

The data suggest that depressive symptoms are highly specific symptoms of DLB, independent of other features of this disorder. The GDS could be used as a subsidiary tool in differentiating DLB from AD and is more useful than clinical observations of depression.

Quality of life in dementia patients in Athens, Greece: predictive factors and the role of caregiver-related factors

BACKGROUND

Quality of life (QOL) is increasingly recognized as the main target of currently available dementia care. Its assessment has grown exponentially in the dementia field, but few studies have examined predictive factors for QOL taking caregiver variables into account. We examined patient and caregiver factors related to the QOL of dementia patients.

METHODS

The study design was cross-sectional. 161 couples of community residing dementia patients and their primary caregivers were interviewed. QOL was measured by the ADRQL, a proxy-rated, dementia-specific QOL instrument. Demographic factors were collected and clinical characteristics assessed using validated scales.

RESULTS

In univariate analyses several patient and caregiver characteristics appeared associated with patient QOL. In multivariate analyses, independent predictors of worse patient QOL were behavioral and depressive symptoms of dementia patients, dependency in basic activities of daily living, poorer cognitive function, use of antipsychotic medication, caregiver burden, and caregiver not being an adult child. The adjusted R2 of the final, seven-factor model was 0.598.

CONCLUSIONS

QOL for a person with dementia is a complex issue that is associated with several patient and caregiver factors. Efforts to improve patients' QOL should be addressed for both patients and caregivers. The measurement of QOL should be included, when possible, as a standard measurement tool, in everyday dementia clinical practice.

Autonomic dysfunction in neurodegenerative dementias

Syncope associated to orthostatic hypotension (OH), urinary incontinence and constipation is common symptoms in demented patients, mainly in dementia with Lewy bodies (DLB) and in Parkinson's disease dementia (PDD). Alzheimer's disease (AD) and fronto temporal lobar degeneration (FTLD) show less autonomic dysfunction. Urinary symptoms are a prominent component of normal pressure hydrocephalus (NPH). There are non invasive tests including standard cardiovascular tests, 123 I-metaiodobenzylguanide (MIBG) cardiac scintigraphy, urodynamic tests, gastrointestinal motility studies, sweating reflexes and pupillary responses that assess autonomic dysfunction in these patients. The study of autonomic symptoms and abnormal tests in patients with dementia is useful to prevent morbidity due falls, severe constipation and to avoid side effects of drugs that interfere with autonomic function.

Impact of rivastigmine patch and capsules on activities of daily living in Alzheimer's disease

BACKGROUND

Rivastigmine patches provide similar efficacy to rivastigmine capsules with a lower incidence of gastrointestinal side effects in patients with probable Alzheimer's disease (AD).

METHODS

Post hoc analysis of a 24-week, prospective, international, randomized, double-blind, placebo- and active-controlled trial. Patients (n = 892) with probable AD received rivastigmine transdermal patches (9.5 mg/24 hours [10 cm(2)]), rivastigmine capsules (6 mg twice daily), or placebo, and impact on activities of daily living (ADLs) was assessed utilizing 3 subscales: basic, high-level function, and autonomy.

RESULTS

At week 24, both rivastigmine groups demonstrated significantly superior performance in Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL) Total Score versus placebo (rivastigmine patch, P = .013; capsules, P = .039). Overall, both rivastigmine formulations provided benefits in ADL subscales. For basic ADLs, rivastigmine capsules performed significantly better than placebo (P = .012). For high-level function ADLs, rivastigmine patch performed better than placebo (P = .056). For autonomy ADLs, rivastigmine patch performed significantly better than placebo (P = .017).

CONCLUSION

Rivastigmine patches and capsules provide significant effects in both total and subscale ADLs in patients with probable AD.

Health-related quality of life among community-dwelling patients with intractable neurological diseases and their caregivers in Japan

AIMS

The aims of this study were: (i) to clarify the general quality of life (QOL) of patients with intractable neurological disease; (ii) to clarify the general QOL of the caregivers of these patients; and (iii) to explore the association of QOL in patient-caregiver pairs.

METHODS

A cross-sectional survey was conducted between November 2003 and May 2004 among community-dwelling patients diagnosed with Parkinson's disease (PD), spinocerebellar degeneration (SCD), multiple system atrophy (MSA), and amyotrophic lateral sclerosis (ALS) and their caregivers using a mailed, self-administered questionnaire. To measure QOL, we used the Medical Outcome Study 36-Item Short Form (SF-36) for patients and the short form of the health-related QOL scale SF-36 (SF-8) for caregivers.

RESULTS

A total of 418 questionnaires were analyzed. For the patients, all of the general QOL domains of the SF-36 were significantly lower than the national standard value for all of the diagnoses. Physical function, role physical, and role emotional domains were also low. For caregivers, all of the QOL summary scores of the SF-8 for all diagnoses were significantly lower than the national standard value. Although there were several significant correlations of QOL between patients and caregivers, overall the correlations were low.

CONCLUSIONS

Support for patients with neurological diseases and their caregivers is needed in order to maintain physical and mental QOL.

Differences in functional impairment across subtypes of dementia

BACKGROUND

Dementia is a cause of disability in later life. Despite the importance of functional status to the diagnosis of dementia, limited information exists on differences in functional limitations by dementia subtype. We conducted a cross-sectional analysis using the Aging, Demographics, and Memory Study (ADAMS) to determine the extent of functional impairment among older adults with dementia due to different etiologies.

METHODS

The ADAMS sample consisted of 856 individuals aged 71 years and older originally surveyed as part of the Health and Retirement Study. Based on a comprehensive in-person cognitive evaluation, respondents were assigned to diagnostic categories of normal cognition, cognitive impairment not demented, and demented. Dementia subtypes were grouped into three categories: vascular dementia (VaD), Alzheimer's dementia (AD), and dementia due to other etiologies. For 744 of the 856 respondents, a proxy informant completed a questionnaire asking whether the respondent had difficulty completing instrumental activities of daily living and activities of daily living (ADLs).

RESULTS

Of 744 ADAMS participants, 263 had dementia: 199 (70.5%) with AD, 42 (16.9%) with VaD, and 22 (12.6%) were demented due to other etiologies. After adjustment for demographics, chronic illnesses, and dementia severity, participants with VaD (odds ratio [OR] 5.74; 95% confidence interval [CI] 2.60-12.69) and other etiologies of dementia (OR 21.23; 95% CI 7.25-62.16) were more likely to have greater than or equal to four ADL limitations compared with those with AD.

CONCLUSIONS

VaD is associated with significantly more ADL limitations than AD. These physical limitations should be considered when designing adult day care programs, which adequately accommodate the needs of non-AD patients.

Carers' narratives: finding dementia with Lewy bodies experiences

Carers' narratives provide a unique insight into the caring experience. From a human interest perspective they have appeal to the general population; however, they also target and are read by niche audiences - families striving to understand the challenges of the caring role. This article examines four carer narratives and their relevance to particular niche audiences; three classified from the information provided on their book covers as pertaining to Alzheimer's disease and one to Parkinson's disease. It explores the impact of care on the caregivers and reviews the promoted diagnoses in light of the current understanding of dementia with Lewy bodies. The author argues that the information provided in the titles, in good faith, may not reflect the content of the narratives and that three of these narratives may provide carers of people who have dementia with Lewy bodies with insights into the challenges that this disease presents.

Predictors and course of health-related quality of life in Parkinson's disease

We investigated how health related quality of life (HRQL) changes over time in a population-based cohort of patients with Parkinson's disease (PD), and which factors predict a lower level of HRQL in these patients. Of 227 patients with PD assessed at baseline and followed prospectively, information on HRQL-status was obtained in 111 subjects 4 years and 82 patients 8 years after inclusion. HRQL was measured by the Nottingham Health Profile (NHP). Analyses were conducted using generalized estimating equation models. The NHP total score (P < 0.001) and scores in all NHP dimensions except for sleep worsened significantly during follow-up. Steepest slope was found for the domain physical mobility (3.16, 95% CI 2.39-3.92), followed by the domains social isolation (2.22, 95% CI 1.52-2.93) and emotional reactions (1.36, 95% CI 0.74-1.97). In addition to follow-up time, higher Hoehn and Yahr staging, higher Montgomery and Aasberg Depression Rating Scale scores, and presence of insomnia at baseline were associated with lower levels of overall HRQL during follow-up. We conclude that PD has an increasing impact on HRQL as the disease progresses. During long-term follow-up, deterioration in physical mobility was the most important single factor contributing to decline in HRQL in our cohort, although distress of nonmotor character as a whole outweighed the impact of distress in physical mobility on overall HRQL. More advanced disease, higher severity of depressive symptoms, and presence of insomnia were found to be important and independent predictors of poor HRQL. (c) 2008 Movement Disorder Society.

Efficacy, safety and tolerability of rivastigmine capsules in patients with probable vascular dementia: the VantagE study

OBJECTIVE

The aim was to evaluate the efficacy, safety and tolerability of rivastigmine capsules in patients diagnosed with probable vascular dementia (VaD).

METHODS

VantagE (Vascular Dementia trial studying Exelon) was a 24-week, multicentre, double-blind study. VaD patients aged 50-85 years were randomized to rivastigmine capsules (3-12 mg/day) or placebo. Efficacy assessments included global and cognitive performances, activities of daily living and neuropsychiatric symptoms. Adverse events were recorded. Additional exploratory analyses determined whether heterogeneity in pathologies and symptoms extended to differential treatment effects.

TRIAL REGISTRATION

NCT00099216.

RESULTS

710 patients were randomized. Rivastigmine demonstrated superiority over placebo on three measures of cognitive performance (Vascular Dementia Assessment Scale, Alzheimer's Disease Assessment Scale cognitive subscale, Mini-Mental State Examination; all p< or = 0.05, intent-to-treat population [ITT]), but not other outcomes. Predominant adverse events were nausea and vomiting. Exploratory analyses indicated that older patients (> or =75 years old), assumed more likely to also have Alzheimer's disease (AD) pathology, demonstrated significant cognitive responses to rivastigmine and a safety profile similar to that seen in AD patients. Younger patients, assumed less likely to have concomitant AD pathology, showed no efficacy response and were associated with slight elevations of blood pressure, cerebrovascular accidents and mortality. Rivastigmine-placebo differences in patients with, versus those without, medial temporal atrophy (also suggestive of concomitant AD) showed a numerical difference similar to that seen between the older versus younger patients, but did not attain statistical significance.

CONCLUSION

Consistent with trials evaluating other cholinesterase inhibitors, rivastigmine did not provide consistent efficacy in probable VaD. The efficacy apparent on cognitive outcomes was derived from effects in older patients likely to have concomitant Alzheimer pathology. This is supportive of an existing argument that the putative cholinergic deficit in VaD reflects the presence of concomitant Alzheimer pathology.