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Ryvicker M, Barrón Y, Song J, Zolnoori M, Shah S, Burgdorf JG, Noble JM, Topaz M. Using Natural Language Processing to Identify Home Health Care Patients at Risk for Diagnosis of Alzheimer's Disease and Related Dementias. J Appl Gerontol 2024:7334648241242321. [PMID: 38556756 DOI: 10.1177/07334648241242321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024] Open
Abstract
This study aimed to: (1) validate a natural language processing (NLP) system developed for the home health care setting to identify signs and symptoms of Alzheimer's disease and related dementias (ADRD) documented in clinicians' free-text notes; (2) determine whether signs and symptoms detected via NLP help to identify patients at risk of a new ADRD diagnosis within four years after admission. This study applied NLP to a longitudinal dataset including medical record and Medicare claims data for 56,652 home health care patients and Cox proportional hazard models to the subset of 24,874 patients admitted without an ADRD diagnosis. Selected ADRD signs and symptoms were associated with increased risk of a new ADRD diagnosis during follow-up, including: motor issues; hoarding/cluttering; uncooperative behavior; delusions or hallucinations; mention of ADRD disease names; and caregiver stress. NLP can help to identify patients in need of ADRD-related evaluation and support services.
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Affiliation(s)
- Miriam Ryvicker
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - Yolanda Barrón
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - Jiyoun Song
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | | | - Shivani Shah
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - Julia G Burgdorf
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - James M Noble
- Columbia University Medical Center, New York, NY, USA
| | - Maxim Topaz
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
- Columbia University Medical Center, New York, NY, USA
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Arafa A, Teramoto M, Maeda S, Sakai Y, Nosaka S, Gao Q, Kawachi H, Kashima R, Matsumoto C, Kokubo Y. Playing a musical instrument and the risk of dementia among older adults: a systematic review and meta-analysis of prospective cohort studies. BMC Neurol 2022; 22:395. [PMID: 36303117 PMCID: PMC9608922 DOI: 10.1186/s12883-022-02902-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Engaging in leisure activities was suggested to protect older adults from dementia. However, the association between playing a musical instrument and the risk of dementia is not well-established. This study aimed to investigate this association in older adults using a systematic review and meta-analysis of prospective cohort studies. Methods Pooled hazard ratio (HR) and 95% confidence interval (CI) of having dementia for older adults playing a musical instrument were calculated using the random-effects model. We performed the I2 statistic to detect heterogeneity across studies and the test for funnel plot asymmetry to assess publication bias. The risk of bias assessment was conducted using the modified Newcastle–Ottawa Scale. Results A total of three prospective cohort studies were found eligible: two from the U.S. and one from Japan. Playing a musical instrument, in the meta-analysis, was significantly associated with a decreased risk of dementia (HR = 0.64; 95% CI: 0.41, 0.98) among older adults. No signs of significant heterogeneity across studies (I2 = 23.3% and p-heterogeneity = 0.27) or publication bias (z= -1.3 and p-publication bias = 0.18) were identified. Conclusion Playing a musical instrument was associated with a decreased risk of dementia among older adults. Older adults should be encouraged to engage in leisure activities, especially playing musical instruments. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02902-z.
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Affiliation(s)
- Ahmed Arafa
- grid.410796.d0000 0004 0378 8307Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe- Shinmachi, 564-8565 Suita, Osaka Japan ,grid.411662.60000 0004 0412 4932Department of Public Health, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Masayuki Teramoto
- grid.410796.d0000 0004 0378 8307Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe- Shinmachi, 564-8565 Suita, Osaka Japan ,grid.266102.10000 0001 2297 6811Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | - Saori Maeda
- grid.410796.d0000 0004 0378 8307Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe- Shinmachi, 564-8565 Suita, Osaka Japan
| | - Yukie Sakai
- grid.410796.d0000 0004 0378 8307Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe- Shinmachi, 564-8565 Suita, Osaka Japan
| | - Saya Nosaka
- grid.410796.d0000 0004 0378 8307Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe- Shinmachi, 564-8565 Suita, Osaka Japan
| | - Qi Gao
- grid.410796.d0000 0004 0378 8307Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe- Shinmachi, 564-8565 Suita, Osaka Japan
| | - Haruna Kawachi
- grid.410796.d0000 0004 0378 8307Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe- Shinmachi, 564-8565 Suita, Osaka Japan ,grid.136593.b0000 0004 0373 3971Department of Environmental Medicine and Population Sciences, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Rena Kashima
- grid.410796.d0000 0004 0378 8307Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe- Shinmachi, 564-8565 Suita, Osaka Japan ,grid.136593.b0000 0004 0373 3971Department of Cardiovascular Pathophysiology and Therapeutics, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Chisa Matsumoto
- grid.412781.90000 0004 1775 2495Department of Cardiology, Center for Health Surveillance and Preventive Medicine, Tokyo Medical University Hospital, Shinjuku, Japan
| | - Yoshihiro Kokubo
- grid.410796.d0000 0004 0378 8307Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe- Shinmachi, 564-8565 Suita, Osaka Japan
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A Survey on Treatment Status of Korean Medicine Doctors for the Behavioral and Psychological Symptoms of Dementia: Preliminary Data for Guidance of Integrative Care. Healthcare (Basel) 2022; 10:healthcare10020269. [PMID: 35206883 PMCID: PMC8872266 DOI: 10.3390/healthcare10020269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 12/10/2022] Open
Abstract
Behavioral and psychological symptoms of dementia (BPSD) are major causes of care burden in patients with dementia. Integrative care, including Western medicine (WM) and Korean medicine (KM), can be an attractive option for this condition. To investigate the experience and perceptions of dementia care; experience, knowledge, and perceptions of management for BPSD; the need for guidance of integrative care for BPSD management, KM doctors were surveyed. A total of 137 KM doctors completed the survey. Most institutions where the participants worked were able to provide integrative care services (88.32%). The rate of referral for dementia patients from the WM to KM departments was also highest in the convalescent hospital setting (94.92%), while the rate was lowest in the public health center setting (38.46%). The common purpose of KM treatments for patients with dementia included “psychological symptom treatment” (37.23%); however, the number of referrals from WM to KM departments for BPSD management was relatively few (25.64%). Participants perceived that knowledge about KM or integrative care for BPSD of non-KMD personnel working at the same institution was generally low. Based on these results, facilitating mutual exchange between WM and KM can help establish integrative care for dementia management in Korea.
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Isik AT, Kocyigit SE, Kaya D, Dost Gunay FS, Erken N, Dokuzlar O, Aydin AE, Ates Bulut E. The Relationship between the Most Common Subtypes of Dementia and Orthostatic Hypotension in Older Adults. Dement Geriatr Cogn Disord 2021; 49:628-635. [PMID: 33735870 DOI: 10.1159/000513978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/21/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It is crucial to evaluate the causes of morbidity and mortality in elderly patients with dementia, such as orthostatic hypotension (OH), which may affect their daily life activities, reduce the quality of life, and increase the caregiver burden. OBJECTIVE We aimed to investigate the relationship between OH and the most common subtypes of dementia in detail. METHODS A total of 268 older adults with dementia diagnosed with Alzheimer's disease (AD), dementia with Lewy bodies (DLB), vascular dementia (VaD), and behavioral variant frontotemporal dementia (bvFTD), and 539 older adults without dementia were included in this prospective study. Comprehensive geriatric assessment including comorbidity, medication evaluation, and the head-up tilt test was also performed. RESULTS Of the participants, 13.8, 8.3, 6.4, and 4.8% had AD, DLB, bvFTD, and VaD, respectively. After adjusting for age, gender, the presence of comorbidities, and usage of OH-induced drugs; AD, DLB, and VaD were associated with OH (odds ratio [OR]: 2.23 confidence interval [CI] 95% 1.31-3.80; p = 0.003; OR: 3.68 CI 95% 1.98-6.83; p < 0.001, and OR: 3.56 CI 95% 1.46-8.69; p = 0.005, respectively). Furthermore, VaD was independently related to diastolic OH (OR: 4.19 CI 95% 1.66-10.57; p = 0.002), whereas AD and DLB were not. CONCLUSIONS This study shows that elderly patients with DLB, AD, and VaD often have OH, a disabling autonomic dysfunction feature. Moreover, diastolic OH may play a role in the development of VaD. Therefore, considering potential complications of OH, it is essential to evaluate OH in the follow-up and management of those patients.
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Affiliation(s)
- Ahmet Turan Isik
- Department of Geriatric Medicine, Unit for Aging Brain and Dementia, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey, .,The Geriatric Science Association, Izmir, Turkey,
| | - Suleyman Emre Kocyigit
- The Geriatric Science Association, Izmir, Turkey.,Department of Geriatric Medicine, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Derya Kaya
- Department of Geriatric Medicine, Unit for Aging Brain and Dementia, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.,The Geriatric Science Association, Izmir, Turkey
| | - Fatma Sena Dost Gunay
- Department of Geriatric Medicine, Unit for Aging Brain and Dementia, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.,The Geriatric Science Association, Izmir, Turkey
| | - Neziha Erken
- Department of Geriatric Medicine, Unit for Aging Brain and Dementia, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.,The Geriatric Science Association, Izmir, Turkey
| | | | - Ali Ekrem Aydin
- The Geriatric Science Association, Izmir, Turkey.,Department of Geriatric Medicine, Sivas State Hospital, Sivas, Turkey
| | - Esra Ates Bulut
- The Geriatric Science Association, Izmir, Turkey.,Department of Geriatric Medicine, Adana State Hospital, Adana, Turkey
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Topaz M, Adams V, Wilson P, Woo K, Ryvicker M. Free-Text Documentation of Dementia Symptoms in Home Healthcare: A Natural Language Processing Study. Gerontol Geriatr Med 2020; 6:2333721420959861. [PMID: 33029550 PMCID: PMC7520927 DOI: 10.1177/2333721420959861] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/18/2020] [Accepted: 08/21/2020] [Indexed: 01/11/2023] Open
Abstract
Background Little is known about symptom documentation related to Alzheimer's disease and related dementias (ADRD) by home healthcare (HHC) clinicians. Objective This study: (1) developed a natural language processing (NLP) algorithm that identifies common neuropsychiatric symptoms of ADRD in HHC free-text clinical notes; (2) described symptom clusters and hospitalization or emergency department (ED) visit rates for patients with and without these symptoms. Method We examined a corpus of -2.6 million free-text notes for 112,237 HHC episodes among 89,459 patients admitted to a non-profit HHC agency for post-acute care with any diagnosis. We used NLP software (NimbleMiner) to construct indicators of six neuropsychiatric symptoms. Structured HHC assessment data were used to identify known ADRD diagnoses and construct measures of hospitalization/ED use during HHC. Results Neuropsychiatric symptoms were documented for 40% of episodes. Common clusters included impaired memory, anxiety and/or depressed mood. One in three episodes without an ADRD diagnosis had documented symptoms. Hospitalization/ED rates increased with one or more symptoms present. Conclusion HHC providers should examine episodes with neuropsychiatric symptoms but no ADRD diagnoses to determine whether ADRD diagnosis was missed or to recommend ADRD evaluation. NLP-generated symptom indicators can help to identify high-risk patients for targeted interventions.
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Affiliation(s)
- Maxim Topaz
- Columbia University, New York, NY, USA.,Visiting Nurse Service of New York, New York, NY, USA
| | | | - Paula Wilson
- Visiting Nurse Service of New York, New York, NY, USA
| | | | - Miriam Ryvicker
- Visiting Nurse Service of New York, New York, NY, USA.,Vital Statistics Consulting, New York, NY, USA
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Glass OM, Hermida AP, Hershenberg R, Schwartz AC. Considerations and Current Trends in the Management of the Geriatric Patient on a Consultation-Liaison Service. Curr Psychiatry Rep 2020; 22:21. [PMID: 32285305 DOI: 10.1007/s11920-020-01147-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To provide consultation-liaison psychiatrists with an updated resource that can assist in the treatment and management of geriatric patients. RECENT FINDINGS The current available literature has not shown any differences in efficacy between haloperidol and second-generation antipsychotics in patients with delirium. When considering relative advantages of forms of antipsychotic administration, there is no support for a superior safety profile of oral compared to intramuscular or intravenous administration. A recent meta-analysis of four randomized controlled trials concluded that when melatonin was administered to older age patients on medical wards, it significantly prevented the incidence of delirium when compared with the control group. While suvorexant administered nightly to elderly patients in acute care settings may lower the incidence of delirium, larger studies are needed to confirm this finding. Despite the black box warning of increased mortality risk in older patients with dementia, antipsychotics may be used with caution by the consultation-liaison (CL) psychiatrist to treat the neuropsychologic symptoms of dementia including hallucinations and psychosis in the hospital setting. While antidepressant studies have focused primarily on citalopram and escitalopram in the treatment of agitation in the setting of dementia, these two medications have not been adequately compared directly to other SSRIs for this condition. It is therefore not clear whether citalopram and escitalopram are more efficacious in treating agitation in the setting of dementia when compared to other SSRIs. While the evidence supporting trazodone's use is limited, it is generally well tolerated and is an option as a PRN for irritability and agitation in patients with Alzheimer's and mixed dementia. While there is some evidence to support the use of acetylcholinesterase inhibitors for treating cognitive impairments and hallucinations in Lewy body dementia, the usefulness of these agents in other forms of dementia is not well studied, and those studies did not show any benefit in the management of acute agitation. It is important to note that memantine can cause or exacerbate agitation and may be the cause of behavioral dysregulation. There is no evidence to support the routine use of benzodiazepines for behavioral improvement in patients with dementia. Escitalopram and citalopram do have a unique pharmacokinetic properties in the sense that they have been found to have 50-56% plasma protein binding, compared to sertraline, fluoxetine, and paroxetine (95% or more). Pooled analyses suggest that antidepressants are more effective than placebo in reducing the symptoms of post-stroke depression. SSRIs are considered first-line antidepressants in stroke patients, who are often elderly with underlying cardiovascular problems. Although treatment with SSRIs is recommended for post-stroke depression, there are no studies providing conclusive data on the superiority of a specific drug. Older age is associated with a better outcome from ECT, with remission rates of approximately 73% to 90% in patients over 65 years. ECT is the treatment of choice for patients with psychotic depression, and elderly patients with psychotic depression have been shown to have a higher remission rate and faster time to response than depressed patients without psychotic symptoms. With the average life expectancy increase, it is projected that 19 million people will reach the age of 85 or higher, an increase from 5.5 million in 2010. With an increasing older population, psychiatric consultation in the management of geriatric patients is becoming more necessary. Psychiatrists must be aware of the unique considerations in elderly patients. In this article, we provide evidence-based guidance to the CL psychiatrist on major issues relating to the older age patient, highlighting recent trends in treatment. First, we provide background on the evaluation of the medically hospitalized geriatric patient. As rates of medical and psychiatric illnesses increase with advancing age, elderly patients are more likely to be taking a higher number of medications as compared to younger patients, and physicians must pay special attention to polypharmacy, including side effects and drug interactions in this group. Next, we focus on the diagnosis, management, and unique needs of the geriatric patient presenting with common clinical syndromes of delirium, dementia, and depression. Delirium and dementia are among the most common causes of cognitive impairment in clinical settings yet are often either unrecognized or misdiagnosed as they may have similar signs and symptoms. In addition, depression is prevalent in older adults, especially in those with comorbid medical illness. Depression can be fatal as the rates of suicide are higher in later life than in any other age group. Consultation can improve the management of elderly patients and prevent unnecessary nursing home placement.
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Affiliation(s)
| | | | - Rachel Hershenberg
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
- Treatment Resistant Depression Program, Emory University, Atlanta, GA, USA
| | - Ann C Schwartz
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.
- Psychiatry Consultation-Liaison Service, Grady Memorial Hospital, 80 Jesse Hill Jr. Dr., Atlanta, GA, USA.
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Naharci MI, Buyukturan O, Cintosun U, Doruk H, Tasci I. Functional Status of Older Adults with Dementia at the End of Life: Is there Still Anything to do? Indian J Palliat Care 2019; 25:197-202. [PMID: 31114103 PMCID: PMC6504749 DOI: 10.4103/ijpc.ijpc_156_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims: There is a lack of data on physical functional status near death of patients with different types of dementia that can contribute to decisions about what kind of care is needed. The aim of this study was to investigate the course of functional status along with the documented reasons for death in participants with dementia who had regularly been followed at a geriatric outpatient unit. Setting and Design: A retrospective observational cohort study was done using the database of a geriatric outpatient clinic. Subjects and Methods: Sociodemographic and medical records of patients with Alzheimer's disease (AD), vascular dementia, mixed dementia, and dementia with Lewy bodies (DLB)/Parkinson's disease dementia (PDD) who had received routine care in a geriatrics outpatient setting for a minimum of 12 months before death were analyzed. Scores for activities of daily living and documented probable causes of death were recorded. Results: Of the 258 participants, 111 (42 female and 69 male) were included in this study. AD was the leading cause of dementia (51.8%). The median duration of survival with dementia was 4 years. The leading causes of death were cardiovascular disease (CVD) (27.0%) and dementia (27.0%) followed by infections (21.6%) and stroke (10.8%). Disability was the highest in patients with DLB/PDD. Conclusions: This study found relatively shorter survival after the diagnosis of dementia when compared to other populations. CVD still appeared as a major cause of that in this particular disease. Most debilitating type of dementia was DLB/PDD.
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Affiliation(s)
- Mehmet Ilkin Naharci
- Department of Geriatrics, University of Health Sciences, Gulhane Faculty of Medicine, Turkish Ministry of Health, Gulhane Training and Research Hospital, Ankara, Turkey.,Department of Internal Medicine, Turkish Ministry of Health, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Oznur Buyukturan
- Department Physiotherapy and Rehabilitation, Ahi Evran University, School of Physical Therapy and Rehabilitation, Kirsehir, Turkey
| | - Umit Cintosun
- Department of Internal Medicine, Turkish Ministry of Health, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Huseyin Doruk
- Department of Internal Medicine, Baskent University, Ankara, Turkey
| | - Ilker Tasci
- Department of Internal Medicine, Turkish Ministry of Health, Gulhane Training and Research Hospital, Ankara, Turkey.,Department of Internal Medicine, Turkish Ministry of Health, Gulhane Training and Research Hospital, Ankara, Turkey
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Tai SY, Hsu CL, Huang SW, Ma TC, Hsieh WC, Yang YH. Effects of multiple training modalities in patients with Alzheimer's disease: a pilot study. Neuropsychiatr Dis Treat 2016; 12:2843-2849. [PMID: 27843319 PMCID: PMC5098772 DOI: 10.2147/ndt.s116257] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE This pilot study investigated the effects of multiple training modalities on cognition, neuropsychiatric symptoms, caregivers' burden, and quality of life in patients with Alzheimer's disease (AD). PATIENTS AND METHODS This intervention study was conducted in 24 patients with AD aged ≥65 years with a Clinical Dementia Rating (CDR) score of 0.5-1. The patients were assigned to receive multiple training modalities (1 hour for each training: Tai Chi, calligraphy, and drawing) over a 6-week period in either the experimental group (n=14) or the comparison group (n=10). A series of neuropsychological tests - namely the Traditional Chinese version Mini-Mental Status Examination, Cognitive Assessment Screening Instrument (CASI), Neuropsychiatric Inventory and the Neuropsychiatric Inventory Caregiver Distress Scale, and the Clinical Dementia Rating Sum of Boxes scale - were conducted at the baseline and after the intervention. The World Health Organization Quality of Life-BREF (WHOQOL-BREF) and Zarit Caregiver Burden Scale were used to assess the quality of life and caregivers' burden, respectively. Independent sample t-test and paired sample t-test were used to analyze the data. RESULTS After the intervention, the experimental group reported higher scores in the orientation domain of CASI (P=0.007) and in the psychiatry domain of WHOQOL-BREF (P=0.042) compared with the comparison group. Caregivers' distress was significantly decreased in the experimental group (P=0.035) but not in the comparison group (P=0.430). CONCLUSION The multiple training modalities improved scores in the orientation domain of CASI and psychiatry domain of WHOQOL-BREF in patients with AD. Moreover, the intervention reduced caregivers' distress.
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Affiliation(s)
- Shu-Yu Tai
- Department of Family Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University; Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Family Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University; Research Center for Environmental Medicine, Kaohsiung Medical University
| | - Chia-Ling Hsu
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University
| | - Shu-Wan Huang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University
| | - Tzu-Chiao Ma
- Graduate Institute of Oral Health Sciences, Kaohsiung Medical University; Mentality Protection Center, Fo Guang Shan Compassion Foundation
| | - Wen-Chien Hsieh
- Department of Social Work, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University; Department of Sociology and Social Work, Kaohsiung Medical University
| | - Yuan-Han Yang
- Department of Neurology, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University; Mentality Protection Center, Fo Guang Shan Compassion Foundation; Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of and Master's Program in Neurology, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
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