Possibilities for the prevention and treatment of cognitive impairment and dementia

Factors associated with public knowledge of and attitudes to dementia: A cross-sectional study

INTRODUCTION

Dementia is a major public health concern but one that continues to be stigmatised. We examine lay knowledge of dementia and attitudes to people with dementia as potential precursors of public anxiety, focusing on the social characteristics associated with (a) the formation of these attitudes, and (b) the perception of the need for restriction and control for people with dementia.

METHODS

Analysis of the 2014 Northern Ireland Life and Times survey, which included questions on knowledge of, attitudes to and personal experience with dementia. We used (a) latent class analysis and (b) logistic regression to examine factors associated with respondent attitudes towards dementia.

RESULTS

Respondents (n = 1211) had relatively good general knowledge of dementia, but limited knowledge of specific risk factors. Negative perceptions of dementia were mitigated somewhat by personal contact. A high proportion of respondents felt that high levels of control were appropriate for people diagnosed with dementia, even at early stages of the disease.

CONCLUSION

Personal antipathy to dementia was highly prevalent despite ongoing public campaigns to increase public awareness of developments in its prevention, treatment and consequent care pathways and hampering efforts to widen social inclusion. Fresh thinking and more resources may be needed to challenge persisting common misapprehension of the condition and the formation of entrenched stigma.

Prevention of cognitive impairment in the midlife women

Forgetfulness is common symptom with age. Especially for midlife women, hormonal cessation by menopausal change is one of the causes in cognitive disorders. And neuropathological changes in brain can lead to mild cognitive impairment (MCI) and eventually dementia. Prevention of MCI is important for decreasing progression to dementia. This article presents therapeutic approaches based on pathophysiologic changes in brain for preventing cognitive decline.

Development of Six Arts, a Culturally Appropriate Multimodal Nonpharmacological Intervention in Dementia

PURPOSE

There is accumulating evidence for the efficacy of nonpharmacological multimodal stimulation interventions in maintaining cognition and improving quality of life in people with mild-to-moderate dementia. However, the complex nature of these interventions limits their application in practice and research. We report here the design and development of a culturally appropriate framework, the Six Arts, to guide delivery of multimodal interventions in a Chinese community.

DESIGN AND DEVELOPMENT

The Six Arts are a core set of Confucian philosophy comprising 6 disciplines of rites, music, archery, charioteering, literacy, and numeracy. They correspond to major mind-body functional domains of social functioning; music and rhythm; visuospatial and fine motor skills; kinesthetic and gross motor skills; language and verbal skills; and executive function. Using Six Arts as a framework, we mapped theoretical principles and evidence-based nonpharmacological interventions of cognitive stimulation, physical exercise, and social activities against the 6 functional domains. From 2011, we field-tested the use of Six Arts in structuring intervention programs in 263 people in a dementia day center in Hong Kong.

RESULTS

The Six Arts was operationalized through the development of an intervention activity database, a scoring system for intensity level, and a service delivery model for application in dementia day centers.

IMPLICATIONS

Six Arts can be used as framework for structuring nonpharmacological group intervention programs in dementia day center in a metropolitan Chinese city. Its cultural appropriateness may facilitate communication and shared decision making with families with dementia in communities influenced by Confucian philosophy.

Randomized Comparison of Mobile and Web-Tools to Provide Dementia Risk Reduction Education: Use, Engagement and Participant Satisfaction

BACKGROUND

Encouraging middle-aged adults to maintain their physical and cognitive health may have a significant impact on reducing the prevalence of dementia in the future. Mobile phone apps and interactive websites may be one effective way to target this age group. However, to date there has been little research investigating the user experience of dementia risk reduction tools delivered in this way.

OBJECTIVE

The aim of this study was to explore participant engagement and evaluations of three different targeted smartphone and Web-based dementia risk reduction tools following a four-week intervention.

METHODS

Participants completed a Web-based screening questionnaire to collect eligibility information. Eligible participants were asked to complete a Web-based baseline questionnaire and were then randomly assigned to use one of the three dementia risk reduction tools for a period of four weeks: (1) a mobile phone application; (2) an information-based website; and (3) an interactive website. User evaluations were obtained via a Web-based follow-up questionnaire after completion of the intervention.

RESULTS

Of 415 eligible participants, 370 (89.16%) completed the baseline questionnaire and were assigned to an intervention group; 200 (54.05%) completed the post-intervention questionnaire. The average age of participants was 52 years, and 149 (75%) were female. Findings indicated that participants from all three intervention groups reported a generally positive impression of the tools across a range of domains. Participants using the information-based website reported higher ratings of their overall impression of the tool, F2,191=4.12, P=.02; how interesting the information was, F2,189=3.53, P=.03; how helpful the information was, F2,192=4.15, P=.02; and how much they learned, F2,188=3.86, P=.02. Group differences were significant between the mobile phone app and information-based website users, but not between the interactive website users and the other two groups. Additionally, participants using the information-based website reported significantly higher scores on their ratings of the ease of navigation, F2,190=4.20, P=.02, than those using the mobile phone app and the interactive website. There were no significant differences between groups on ratings of ease of understanding the information, F2,188=0.27, P=.76. Most participants from each of the three intervention groups indicated that they intended to keep using the dementia risk reduction eHealth tool.

CONCLUSIONS

Overall, results indicated that while participants across all three intervention groups reported a generally positive experience with the targeted dementia risk reduction tools, participants using the information-based website provided a more favorable evaluation across a range of areas than participants using the mobile phone app. Further research is required to investigate whether targeted dementia risk reduction tools, in the form of interactive websites and mobile apps, can be improved to provide benefits above those gained by providing static information alone.

Public knowledge and beliefs about dementia risk reduction: a national survey of Australians

Background

With the dramatically increasing contribution of Alzheimer’s Disease and other forms of dementia to the global burden of disease, countries are being urged to address this as a public health priority. This study investigated whether Australian adults recognise this as an important health issue, and hold beliefs and knowledge that are consistent with recommendations concerning dementia risk reduction. This research was undertaken to guide national brain health awareness and education strategies.

Methods

A cross-sectional telephone survey was undertaken of 1,003 Australians aged 20–75 years. This measured the importance placed on dementia, beliefs and confidence related to risk reduction, knowledge of risk reduction methods, and the perceived age-relevance of these. In analysis the data were stratified by sex, age, educational attainment, household income, language preference and previous exposure to dementia. Multivariable logistic regression was undertaken to identify variables independently associated with beliefs and knowledge.

Results

People aged 60 years and over identified dementia as very important (17.2%) more often than those aged 40–59 years (5.1%) or 20–39 years (2.1%). While 41.5% of respondents believed the risk of dementia could be reduced, 26.9% were very confident that they could achieve this. Mental activity (57.1%) was identified as beneficial much more often than physical activity (31.3%), healthy eating (23.3%) and other cardiovascular health behaviours. Women, people of English-speaking origin, and those having contact with a person with dementia, showed better knowledge of several health behaviours.

Conclusions

Growing attention is being given to population risk reduction to combat the dramatic increase in the burden of disease due to dementia. In Australia many people do not yet hold beliefs and knowledge that support this, which highlights the need for concerted awareness raising that dementia is not an inevitable aspect of ageing, and for education about the role of vascular health in dementia risk reduction.

User perceptions of a dementia risk reduction website and its promotion of behavior change

Background

Several modifiable health and lifestyle factors are consistently associated with dementia risk and it is estimated that significantly fewer people would develop dementia if the incidence of risk factors could be reduced. Despite this, Australians’ awareness of the health and lifestyle factors associated with dementia risk is low. Within a national community education campaign, Alzheimer’s Australia developed a dementia risk reduction website providing information about modifiable risk or protective factors for dementia.

Objective

This study aimed to assess the usefulness of the website content in improving knowledge and enabling adoption of recommended strategies, and to examine what additional resources consumers need.

Methods

Visitors to the website over a 3 month period were invited to complete an online survey, which asked them to rate their knowledge of dementia risk reduction before and after visiting the site, how important monitoring their health related behavior was to them before and after visiting the site, their current behavior related to health and lifestyle factors associated with dementia risk, their intentions to change behavior, and the usefulness of potential additional resources to help them do so.

Results

For this study, 123 Australian adults responded to the survey. 44.7% (55/122) were aged over 60 and 82.1% (98/119) were female. Respondents’ ratings and comments indicated they generally found the content interesting, informative, and helpful to them. Respondents’ ratings of their knowledge about the links between health and lifestyle factors and dementia risk significantly increased after visiting the website (P<.001). Their ratings of how important monitoring what they do in relation to their health and lifestyle factors were also significantly increased after visiting the website (P<.001). Average ratings for how well respondents felt they were doing at the time in relation to specific risk or protective factors were generally high, suggesting many website visitors already had high levels of health motivation and healthy lifestyle behaviors. 55.6% (45/81) said that after visiting the website their intention to make lifestyle changes was strong. Only 27.1% (22/81) said their intention to visit their doctor to discuss dementia risk reduction was strong. Potential additional resources that would help people assess and address their personal dementia risk factors were rated as more helpful than general information resources.

Conclusions

A dementia risk reduction website providing information about the current evidence and practical strategies was of interest and was useful to the Australian community. Benefits for visitors included increased knowledge and increased motivation to address relevant behaviors. Many visitors to the site were already health conscious, indicating that more needs to be done to get dementia risk reduction messages to the wider community. More interactive and personalized resources in future interventions may offer additional benefits to individuals.

Cognitive stimulation during hospitalization improves global cognition of older Taiwanese undergoing elective total knee and hip replacement surgery

AIM

  This article is a report on a pilot study conducted to determine the effects of cognitively stimulating activities in older patients undergoing elective hip and/or knee replacement.

BACKGROUND

  Cognitive decline occurs in 16-35·5% of older hospitalized patients. In-hospital interventions, such as cognitively stimulating activities, might combat cognitive decline. However, evidence supporting such interventions is limited.

METHODS

For this randomized pilot trial, 50 older patients (90% women with a mean age of 72·8 years) were recruited in 2008 from a tertiary medical centre in Taiwan. While hospitalized, participants in the intervention group received a daily nurse-led, individual-based, cognitive-stimulation intervention. The comparison group received usual care. Cognitive function was assessed using Mini-Mental State Examination at admission, discharge and 1 month after discharge.

RESULTS

  The incidence of cognitive decline (≥2-point decline in cognitive score) by hospital discharge was significantly lower for the intervention group (12%) than the usual care group (44%). The intervention group also had better cognitive scores following hospitalization. Upon discharge, participants in the intervention group scored 1·28 points higher than at admission, whereas participants in the usual care declined by 0·76 points. Improvement in cognitive status persisted for the intervention group (+1·33 points) vs. usual care (-0·26 points) at 1 month after discharge. Group differences in changes were statistically significant both at discharge and 1 month afterwards.

CONCLUSION

  Our cognitive-stimulation intervention benefited global cognitive function among older patients undergoing elective hip and/or knee replacement. The benefit persisted at 1 month after discharge.

Is dementia preventable? Focus on Alzheimer's disease

The prevention of dementia, and particularly of Alzheimer's disease, is a major challenge for researchers and clinicians. In this article, the mixture of evidence, observations and hypotheses in the current literature is categorized into four avenues for possible preventive interventions, as suggested by the NIH State-of-the-Science Conference. The main categories are: antihypertensive medications; nutrition; cognitive engagement; and physical activity. There is, as yet, no conclusive evidence, but each category may hold promise for the prevention of dementia. The robust findings are as follows: cognitive engagement and regular physical activity may reduce the risk of Alzheimer's disease; the Mediterranean diet and consumption of omega-3 fatty acids deserves further elucidation; and the meticulous management of risk factors, and especially hypertension, is the infrastructure of Alzheimer's disease prevention.

Persistent cognitive decline in older hospitalized patients in Taiwan

AIM

This paper is a report of a study conducted to determine the prevalence and predictors of persistent and transient cognitive decline in older hospitalized patients over 6 months after hospital discharge.

BACKGROUND

Cognitive decline occurs in 16-35.5% of older hospitalized patients, but this decline may be persistent rather than transient. Distinguishing persistent from transient cognitive decline is clinically useful.

METHODS

For this prospective cohort study, 291 older patients were recruited from five medical and surgical units at a tertiary medical centre in Taiwan between 2004 and 2006. Participants were assessed for cognitive status by scores on the Mini-Mental State Examination at admission, discharge, 3 and 6 months postdischarge. Persistent cognitive decline was defined as continuing score reduction and > or =3-point reduction 6 months postdischarge. Transient decline was defined as > or = 3-point reduction at some stage, with a total decline < 3 points 6 months postdischarge. Findings. The cognitive status of the majority of participants (57.4%, n = 167) decreased > or =3 points during follow-up. Of these decliners, 59 (35.3%) had persistent cognitive decline, with an average 5.32-point reduction 6 months postdischarge. Forty-six (27.5%) participants experienced transient cognitive decline. After multiple adjustments in logistic regression analysis, persistent decline was predicted by no in-hospital functional decline (OR = 0.16, P = 0.002), more re-admissions after discharge (OR = 2.42, P = 0.020), and older age (OR = 1.09, P = 0.048).

CONCLUSION

A new perspective is needed on discharge planning on patients at risk for persistent cognitive decline. Nurses can oversee the delivery of care, identify cognitive decline, refer patients, and educate families on strategies to enhance cognitive functioning for their aging relatives.

Activity loss is associated with cognitive decline in age-related macular degeneration

BACKGROUND/METHODS

The objective of this study was to determine whether relinquishing cognitive, physical, and social activities is associated with an increased risk of cognitive decline in patients with age-related macular degeneration (AMD). We conducted a 3-year longitudinal study of 206 nondemented patients with AMD.

RESULTS

Twenty-three subjects (14.4%) declined cognitively. Age, sex, education, decline in visual acuity, and number of dropped activities were associated with cognitive decline; each additional dropped activity increased the risk by 58%. Subjects who relinquished three activities were 3.87 times (95% confidence interval, 1.95-7.76) more likely to become demented than subjects who relinquished no activities; those who relinquished five activities were 9.54 times (95% confidence interval, 3.05-30.43) more likely. A multivariate model demonstrated that number of dropped activities was a powerful predictor of cognitive decline after controlling for relevant risk factors, particularly for subjects younger than 80 years of age.

CONCLUSIONS

Relinquishing valued activities is associated with an increased risk of cognitive decline in older patients with vision loss caused by AMD. These data suggest the importance of promoting optimal cognitive and physical health in patients with AMD and perhaps other chronic diseases.

Early intervention for cognitive decline: is there a role for multiple medical or behavioural interventions?

AIM

Early medical or behavioural intervention to slow cognitive decline might be a viable strategy for reducing disability and rates of institutional care in older persons. This paper details the published work supporting cross-sectional and longitudinal associations between vascular risk factors, depressive symptoms and progressive cognitive decline. Evidence for the beneficial effects of providing relevant interventions is assessed.

METHODS

Relevant published work from the areas of dementia research, 'vascular depression' and the cognitive benefits that might result from treating vascular risk factors, managing depression or promoting nutrition, cognitive or physical exercise was ascertained from electronic database searches and recent reviews of key areas.

RESULTS

The existing published work does not provide many examples of early intervention strategies that target vascular strategies or active treatment of depression to reduce the rate of cognitive decline. Most studies have major limitations including the evaluation of only single-risk-factor interventions, the observational designs and the inadequate measurement of cognition. An optimal early intervention strategy might be to target multiple risk factors within relevant experimental or health service frameworks.

CONCLUSIONS

Early identification and multifaceted reduction of vascular risk factors, active management of depression, engagement in cognitive activity and physical exercise and promotion of better nutrition might together help to slow some forms of cognitive decline or progression to dementia. This health services approach now requires systematic evaluation.

The aged retinal pigment epithelium/choroid: a potential substratum for the pathogenesis of age-related macular degeneration

Background

Although the statement that age is the greatest risk factor for Age-related macular degeneration (AMD) is widely accepted, the cellular and molecular explanations for that clinical statement are not generally known. A major focus of AMD research is the retinal pigment epithelium (RPE)/choroid. The purpose of this study was to characterize the changes in the RPE/choroid with age that may provide a background for the development of AMD.

Methodology/Principal Findings

We compared the transcriptional profiles, key protein levels and histology of the RPE/choroid from young and old mice. Using three statistical methods, microarray data demonstrated marked changes in the old mouse. There were 315 genes differentially expressed with age; most of these genes were related to immune responses and inflammatory activity. Canonical pathways having significant numbers of upregulated genes in aged RPE/choroid included leukocyte extravasation, complement cascades, natural killer cell signaling and IL-10 signaling. By contrast, the adjacent neural retina showed completely different age-related changes. The levels of proteins that participate in leukocyte extravasation and complement pathways were consistently increased in the normal, aged RPE/choroid. Furthermore, there was increased gene expression and protein levels of leukocyte attracting signal, chemokine ligand 2 (Ccl2) in aged RPE/choroid. In old animals, there was marked extravasation and accumulation of leukocytes from the choroidal circulation onto Bruch's membrane and into the RPE.

Conclusions/Significance

These phenotypic changes indicate that the RPE/choroid in the normal, old mouse has become an immunologically active tissue. There are signals from the normal, aged RPE/choroid which recruit leukocytes from the circulation and activate the complement cascade. These age-related changes that occur in the RPE/choroid with age, to the extent that they occur in the human retina, may provide the background for an error in regulation of immunological activity to cause AMD to appear in an elderly individual.

Complex mental activity and the aging brain: Molecular, cellular and cortical network mechanisms

There is strong evidence to suggest that high levels of complex mental activity can improve clinical outcome from brain injury. What are the neurobiological mechanisms underlying this observation? This paper proposes that complex mental activity induces a spectrum of biological changes on brain structure and function which can be best understood in a multiscalar spatiotemporal framework. Short-term molecular changes may include induction of BDNF, NGF and endopeptidase genes and elevation of the high-energy phosphocreatine-creatine resting state equilibrium. Animal models have implicated these processes in the reduction and even reversal of neurodegenerative changes secondary to mental work. These mechanisms can therefore be described as neuroprotective. Medium-term cellular changes are diverse and include neurogenesis, synaptogenesis, angiogenesis and formation of more complex dendritic branching patterns. Importantly, these effects parallel behavioral improvement, and thus a neurogenerative class of mechanisms is implicated. Finally, in the post-lesion context, computation principles such as efficiency, small world connectivity and functional adaptation are identified as important, with supportive clinical evidence from neuroimaging studies. Thus, dynamic compensatory cortical network mechanisms may also be relevant, yet take some time to evolve. This paper will explore the neurobiological and clinical implications of this framework, in particular in the context of age-related brain disease.