Diagnosis and treatment of dementia: 3. Mild cognitive impairment and cognitive impairment without dementia

Exploring the influence of weather variability and climate change on health outcomes in people living with dementia: A scoping review protocol

Environmental factors resulting from climate change and air pollution are risk factors for many chronic conditions including dementia. Although research has shown the impacts of air pollution in terms of cognitive status, less is known about the association between climate change and specific health-related outcomes of older people living with dementia. In response, we outline a scoping review protocol to systematically review the published literature regarding the evidence of climate change, including temperature and weather variability, on health-related quality of life, morbidity, mobility, falls, the utilization of health resources, and mortality among older adults living with dementia. This scoping review will be guided by the framework proposed by Arksey and O'Malley. Electronic search (Medline, Embase, PsycINFO, CINAHL, Scopus, Web of Science) using relevant subject headings and synonyms for two concepts (older people with dementia, weather/ climate change). No publication date or other restrictions will be applied to the search strategy. No language restriction will be applied in order to understand the impact of non-English studies in the literature. Eligible studies must include older adults (65+years) with dementia living in the community and investigate the impacts of climate change and/or weather on their health-related quality of life, morbidity, mobility, falls, use of health resources and mortality. Two independent reviewers will screen abstracts and select those for a full-text review, perform these reviews, select articles for retention, and extract data from them in a standardized manner. This data will then be synthesized and interpreted. OSF registration: DOI: 10.17605/OSF.IO/YRFM8.

The clinical heterogeneity of subjective cognitive decline: a data-driven approach on a population-based sample

BACKGROUND

subjective cognitive decline (SCD) refers to the subjective experience of cognitive decline in the absence of detectable cognitive impairment. SCD has been largely studied as a risk condition for cognitive decline. Empirical observations suggest that persons with SCD are heterogeneous, including individuals with early Alzheimer's disease and others with psychological vulnerabilities and/or physical comorbidity. The semiology of SCD is still in its infancy, and the features predicting cognitive decline are poorly defined. The present study aims to identify subgroups of SCD using a data-driven approach and study their clinical evolution across 8 years.

METHODS

the study population is the InveCe.Ab population-based cohort, including cognitively unimpaired people aged 70-74 years and followed for 8 years. Hierarchical cluster analysis (HCA) was carried out to identify distinct SCD subgroups based on nine clinical and cognitive features. Longitudinal changes by baseline SCD status were estimated using linear mixed models for cognitive decline and Cox proportional-hazard model for all-cause dementia risk.

RESULTS

out of 956 individuals, 513 were female (54%); and the mean age was 72.1 (SD = 1.3), education was 7.2 (3.3), and 370 (39%) reported cognitive complaints (SCD). The HCA resulted in two clusters (SCD1 and SCD2). SCD2 were less educated and had more comorbidities, cardiovascular risk and depressive symptoms than SCD1 and controls. SCD2 presented steeper cognitive decline (Mini-Mental State Examination; β = -0.31) and increased all-cause dementia risk (hazard-ratio = 3.4).

CONCLUSIONS

at the population level, basic clinical information can differentiate individuals with SCD at higher risk of developing dementia, underlining the heterogeneous nature of this population even in a sample selected for a narrow age range, in a specific geographic area.

Histopathological evaluation of insulin-DMSO formula designed for direct nose-to-brain delivery

The combination of insulin and DMSO is a patented (Publication No US8987199B2), noninvasive, pharmaceutically strategized preparation for direct nose-to-brain delivery (DN2BD) suggested for the treatment of Alzheimer's disease (AD). Although its main ingredients have been individually researched, no histopathological investigations have been conducted to address this combination effect on the CNS and nasal tissues in animals. The present work was, therefore, designed to investigate the potential histopathological changes induced by this new pharmaceutical combination using a newly developed refractory staining method. The findings presented herein showed no signs of treatment-related lesions or behavioral changes in Sprague Dawley rats following a three-month successive treatment with two strengths of the formula.

Factors Associated With Cognitive Impairment in Heart Failure With Preserved Ejection Fraction

BACKGROUND

Cognitive impairment is prevalent in heart failure and is associated with higher mortality rates. The mechanism behind cognitive impairment in heart failure with preserved ejection fraction (HFpEF) has not been established.

OBJECTIVE

The aim of this study was to evaluate associations between abnormal cardiac hemodynamics and cognitive impairment in individuals with HFpEF.

METHODS

A secondary analysis of Atherosclerosis Risk in Communities (Atherosclerosis Risk in Communities) study data was performed. Participants free of stroke or dementia who completed in-person assessments at visit 5 were included. Neurocognitive test scores among participants with HFpEF, heart failure with reduced ejection fraction (HFrEF), and no heart failure were compared. Sociodemographics, comorbid illnesses, medications, and echocardiographic measures of cardiac function that demonstrated significant (P < .10) bivariate associations with neurocognitive test scores were included in multivariate models to identify predictors of neurocognitive test scores among those with HFpEF. Multiple imputation by chained equations was used to account for missing values.

RESULTS

Scores on tests of attention, language, executive function, and global cognitive function were worse among individuals with HFpEF than those with no heart failure. Neurocognitive test scores were not significantly different among participants with HFpEF and HFrEF. Worse diastolic function was weakly associated with worse performance in memory, attention, and language. Higher cardiac index was associated with worse performance on 1 test of attention.

CONCLUSIONS

Cognitive impairment is prevalent in HFpEF and affects several cognitive domains. The current study supports the importance of cognitive screening in patients with heart failure. An association between abnormal cardiac hemodynamics and cognitive impairment was observed, but other factors are likely involved.

Smart Textiles for Improved Quality of Life and Cognitive Assessment

Smart textiles can be used as innovative solutions to amuse, meaningfully engage, comfort, entertain, stimulate, and to overall improve the quality of life for people living in care homes with dementia or its precursor mild cognitive impairment (MCI). This concept paper presents a smart textile prototype to both entertain and monitor/assess the behavior of the relevant clients. The prototype includes physical computing components for music playing and simple interaction, but additionally games and data logging systems, to determine baselines of activity and interaction. Using microelectronics, light-emitting diodes (LEDs) and capacitive touch sensors woven into a fabric, the study demonstrates the kinds of augmentations possible over the normal manipulation of the traditional non-smart activity apron by incorporating light and sound effects as feedback when patients interact with different regions of the textile. A data logging system will record the patient’s behavioral patterns. This would include the location, frequency, and time of the patient’s activities within the different textile areas. The textile will be placed across the laps of the resident, which they then play with, permitting the development of a behavioral profile through the gamification of cognitive tests. This concept paper outlines the development of a prototype sensor system and highlights the challenges related to its use in a care home setting. The research implements a wide range of functionality through a novel architecture involving loosely coupling and concentrating artifacts on the top layer and technology on the bottom layer. Components in a loosely coupled system can be replaced with alternative implementations that provide the same services, and so this gives the solution the best flexibility. The literature shows that existing architectures that are strongly coupled result in difficulties modeling different individuals without incurring significant costs.

Impact of the introduction of falls risk assessment toolkit on falls prevention and psychotropic medicines' utilisation in Walsall: an interrupted time series analysis

OBJECTIVE

To determine the impact of the introduction of a falls risk assessment toolkit (FRAT) in a UK medical centre on the number and cost of non-elective admissions for falls and psychotropic medication utilisation.

DESIGN

Interrupted time series analysis quantifying the number and cost of non-elective admissions for falls and primary care use data for Rushall Medical Centre before and after the implementation of FRAT at July 2017.

SETTING

Data on the monthly number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service were provided by Walsall Clinical Commissioning Group. Primary care prescribing cost and volume data for Rushall Medical Centre was derived from the Openprescribing.net website for prescriptions dispensed between April 2015 and November 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

The number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service, and the volume of utilisation of psychotropic medicines.

RESULTS

Following the implementation of FRAT at Rushall Medical Centre in July 2017, the number of non-elective admissions for falls decreased at a rate of 0.414 admissions per month (p<0.033, 95% CI -0.796 to -0.032). The utilisation of psychotropic medications (alimemazine, citalopram, escitalopram, fluoxetine, mirtazapine, olanzapine and risperidone) decreased. The expenditure on psychotropic medications prescribed/used at Rushall Medical Centre decreased by at least £986 per month (p<0.001, 95% CI -2067 to -986).

CONCLUSIONS

The implementation of FRAT at Rushall Medical Centre was associated with a reduction in the number of non-elective admissions for falls. Assessment of these patients together with deprescribing of psychotropic medications resulted in a reduction in the number of non-elective admissions for falls and associated costs.

Synergistic Neuroprotective Effects of Mature Silkworm and Angelica gigas Against Scopolamine-Induced Mild Cognitive Impairment in Mice and H2O2-Induced Cell Death in HT22 Mouse Hippocampal Neuronal Cells

We previously reported that mature Bombyx mori silkworm (SW) ameliorated scopolamine (Sco)-induced amnesia, and Angelica gigas (AG) prevented cognitive impairment. SW is known for its gastroprotective effects such as improving liver function and alleviating the effects of Parkinson's disease. AG is known for its neuroprotective effects and for lowering the effects of low-density lipoprotein cholesterol. However, the neuroprotective effect of combined SW and AG (SWA-1) treatment and the underlying molecular mechanism by which SWA-1 regulates neurodegenerative diseases remains unclear. We evaluated the neuroprotective effect of SWA-1 against Sco-induced mild cognitive impairment in mice and H₂O₂-induced cell death in HT22 mouse hippocampal neuronal cells and elucidated the underlying molecular mechanism. Morris water maze and Y-maze tests were performed to examine the learning and memory abilities of mice. The underlying molecular mechanism was investigated by using western blotting. We demonstrated that SWA-1 significantly protects against H₂O₂-induced cell death in HT22 mouse hippocampal neuronal cells. SWA-1 also significantly reversed Sco-induced spatial learning and memory impairment. Specifically, SWA-1 upregulates the protein levels of phosphorylated extracellular signal-related kinase (Erk1/2) and phosphorylated p38 MAP kinase (p38). SWA-1 remarkably decreased the apoptotic index Bax/Bcl2 expression in the hippocampus of Sco-treated mice. Our results suggest that SWA-1 may be administered as alternative therapy for cognitive impairment and neurodegenerative diseases and should be studied further in human trials.

[Cognitive impairment in patients with cardiovascular risk: DECOG study]

OBJECTIVE

To evaluate the correlation between cardiovascular risk factors (CRF) and mild cognitive impairment (MCI) in the primary care setting.

MATERIALS AND METHODS

Observational, cross-sectional and multicenter study conducted in the setting of primary care. Information regarding demographic variables, CRF, comorbidities, and cognitive impairment determined by Mini-Mental State Examination (MMSE) score was collected. These data were correlated by multivariate analysis.

RESULTS

Data from a total of 458 patients were collected. CRFs significantly negative correlated with MCI were patient age, presence of cardiovascular disease, family history of dyslipemia, diastolic blood pressure and cholesterol levels; while factors such as education level and folic acid levels were significant and positive related to higher MMSE scores.

CONCLUSIONS

This study confirms that the presence of CRF impacts on MCI development, already detectable in the primary care setting. High cholesterol levels and high blood pressure are key elements in MCI, and therefore, measures to control these two conditions from primary care should be reinforced in order to stop the development of dementias.

Molecular Factors Mediating Neural Cell Plasticity Changes in Dementia Brain Diseases

Neural plasticity-the ability to alter a neuronal response to environmental stimuli-is an important factor in learning and memory. Short-term synaptic plasticity and long-term synaptic plasticity, including long-term potentiation and long-term depression, are the most-characterized models of learning and memory at the molecular and cellular level. These processes are often disrupted by neurodegeneration-induced dementias. Alzheimer's disease (AD) accounts for 50% of cases of dementia. Vascular dementia (VaD), Parkinson's disease dementia (PDD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD) constitute much of the remaining cases. While vascular lesions are the principal cause of VaD, neurodegenerative processes have been established as etiological agents of many dementia diseases. Chief among such processes is the deposition of pathological protein aggregates in vivo including β-amyloid deposition in AD, the formation of neurofibrillary tangles in AD and FTD, and the accumulation of Lewy bodies composed of α-synuclein aggregates in DLB and PDD. The main symptoms of dementia are cognitive decline and memory and learning impairment. Nonetheless, accurate diagnoses of neurodegenerative diseases can be difficult due to overlapping clinical symptoms and the diverse locations of cortical lesions. Still, new neuroimaging and molecular biomarkers have improved clinicians' diagnostic capabilities in the context of dementia and may lead to the development of more effective treatments. Both genetic and environmental factors may lead to the aggregation of pathological proteins and altered levels of cytokines, such that can trigger the formation of proinflammatory immunological phenotypes. This cascade of pathological changes provides fertile ground for the development of neural plasticity disorders and dementias. Available pharmacotherapy and disease-modifying therapies currently in clinical trials may modulate synaptic plasticity to mitigate the effects neuropathological changes have on cognitive function, memory, and learning. In this article, we review the neural plasticity changes seen in common neurodegenerative diseases from pathophysiological and clinical points of view and highlight potential molecular targets of disease-modifying therapies.

Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD)5: Guidelines for management of vascular cognitive impairment

INTRODUCTION

Vascular disease is a common cause of dementia, and often coexists with other brain pathologies such as Alzheimer's disease to cause mixed dementia. Many of the risk factors for vascular disease are treatable. Our objective was to review evidence for diagnosis and treatment of vascular cognitive impairment (VCI) to issue recommendations to clinicians.

METHODS

A subcommittee of the Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD) reviewed areas of emerging evidence. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assign the quality of the evidence and strength of the recommendations.

RESULTS

Using standardized diagnostic criteria, managing hypertension to conventional blood pressure targets, and reducing risk for stroke are strongly recommended. Intensive blood pressure lowering in middle-aged adults with vascular risk factors, using acetylsalicylic acid in persons with VCI and covert brain infarctions but not if only white matter lesions are present, and using cholinesterase inhibitors are weakly recommended.

CONCLUSIONS

The CCCDTD has provided evidence-based recommendations for diagnosis and management of VCI for use nationally in Canada, that may also be of use worldwide.

CCCDTD5 recommendations on early and timely assessment of neurocognitive disorders using cognitive, behavioral, and functional scales

INTRODUCTION

Earlier diagnosis of neurocognitive disorders and neurodegenerative disease is needed to implement preventative interventions, minimize harm, and reduce risk of exploitation in the context of undetected disease. Along the spectrum from subjective cognitive decline (SCD) to dementia, evidence continues to emerge with respect to detection, staging, and monitoring. Updates to previous guidelines are required for clinical practice.

METHODS

A subcommittee of the 5th Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD) reviewed emerging evidence to address the following: (1) Is there a role for screening at-risk patients without clinical concerns? In what context is assessment for dementia appropriate? (2) What tools can be used to evaluate patients in whom cognitive decline is suspected? (3) What important information can be gained from an informant, using which measures? (4) What instruments can be used to get more in-depth information to diagnose mild cognitive impairment (MCI) or dementia? (5) What is the approach to those with cognitive concerns but without objective changes (ie, SCD)? (6) How do we track response to treatment and change over time? The Grading of Recommendations Assessment, Development, and Evaluation system was used to rate quality of the evidence and strength of the recommendations.

RESULTS

We recommend instruments to assess and monitor cognition, behavior, and function across the cognitive spectrum, including reports from patient and informant. We recommend against screening asymptomatic older adults but recommend investigation for self- or informant reports of changes in cognition, emergence of behavioral or psychiatric symptoms, or decline in function or self-care. Standardized assessments should be used for cognitive and behavioral change that have sufficient validity for use in clinical practice.

DISCUSSION

The CCCDTD5 provides evidence-based recommendations for detection, assessment, and monitoring of neurocognitive disorders. Although these guidelines were developed for use in Canada, they may also be useful in other jurisdictions.

Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia

Since 1989, four Canadian Consensus Conferences on the Diagnosis and Treatment of Dementia (CCCDTD) have provided evidence-based dementia guidelines for Canadian clinicians and researchers. We present the results of the 5th CCCDTD, which convened in October 2019, to address topics chosen by the steering committee to reflect advances in the field, and build on previous guidelines. Topics included: (1) utility of the National Institute on Aging research framework for clinical Alzheimer's disease (AD) diagnosis; (2) updating diagnostic criteria for vascular cognitive impairment, and its management; (3) dementia case finding and detection; (4) neuroimaging and fluid biomarkers in diagnosis; (5) use of non-cognitive markers of dementia for better dementia detection; (6) risk reduction/prevention; (7) psychosocial and non-pharmacological interventions; and (8) deprescription of medications used to treat dementia. We hope the guidelines are useful for clinicians, researchers, policy makers, and the lay public, to inform a current and evidence-based approach to dementia.

Evaluating the Memory Enhancing Effects of Angelica gigas in Mouse Models of Mild Cognitive Impairments

(1) Background: By 2050, it is estimated that 130 million people will be diagnosed with dementia, and currently approved medicines only slow the progression. So preventive intervention is important to treat dementia. Mild cognitive impairment is a condition characterized by some deterioration in cognitive function and increased risk of progressing to dementia. Therefore, the treatment of mild cognitive impairment (MCI) is a possible way to prevent dementia. Angelica gigas reduces neuroinflammation, improves circulation, and inhibits cholinesterase, which can be effective in the prevention of Alzheimer’s disease and vascular dementia and the progression of mild cognitive impairment. (2) Methods: Angelica gigas (AG) extract 1 mg/kg was administered to mildly cognitive impaired mice, models based on mild traumatic brain injury and chronic mild stress. Then, spatial, working, and object recognition and fear memory were measured. (3) Result: Angelica gigas improved spatial learning, working memory, and suppressed fear memory in the mild traumatic brain injury model. It also improved spatial learning and suppressed cued fear memory in the chronic mild stress model animals. (4) Conclusions: Angelica gigas can improve cognitive symptoms in mild cognitive impairment model mice.

Potential Fluid Biomarkers for the Diagnosis of Mild Cognitive Impairment

Mild cognitive impairment (MCI) is characterized by a level of cognitive impairment that is lower than normal for a person’s age, but a higher function than that that observed in a demented person. MCI represents a transitional state between normal aging and dementia disorders, especially Alzheimer’s disease (AD). Much effort has been made towards determining the prognosis of a person with MCI who will convert to AD. It is now clear that cerebrospinal fluid (CSF) levels of Aβ40, Aβ42, total tau and phosphorylated tau are useful for predicting the risk of progression from MCI to AD. This review highlights the advantages of the current blood-based biomarkers in MCI, and discusses some of these challenges, with an emphasis on recent studies to provide an overview of the current state of MCI.

Determining Filipino Normative Data for a Battery of Neuropsychological Tests: The Filipino Norming Project (FNP)

Background

Filipino normative data for neuropsychological tests are lacking.

Objectives

This study aimed to determine the Filipino normative data for the Filipino Norming Project (FNP) Neuropsychological Battery, combining the Alzheimer's Disease Assessment Scale – Cognitive (ADAS-Cog) and the Neuropsychological Test Battery from the Uniform Dataset of Alzheimer's Disease Center (UDS-ADC).

Methods

We recruited participants 60 years and older with normal cognition (MMSE score of 25 and above and did not fulfill criteria for dementia according to DSM-IV criteria). Psychologists administered the tests to the study participants. We conducted multivariate analyses to study the effect of age, gender, and education on test performance.

Results

A total of 191 participants underwent the FNP Neuropsychological Test Battery. The mean age was 68.8 years (SD 5.4). The majority were female (84.1%). The mean score of ADAS-Cog was 9.98 (SD 4.74). The effect of education was prominent throughout the cognitive domains tested while the effect of age was limited to a few cognitive domains. The mean ADAS-Cog scores were 11.80 ± 4.40 for primary education, 9.93 ± 5.08 for secondary, and 8.15 ± 3.95 for tertiary. On average, women scored 2.75 points lower than men and performed better on the verbal components. Men performed better on the constructional praxis component. The same effect of education and gender was observed for the UDS-ADC.

Conclusion

For the first time, normative data are available for the ADAS-Cog and UDS-ADC for a Filipino older population. This study stresses the importance of establishing population-specific normative data, taking into account the specific sociocultural and linguistic context of that population.

Prevalence of Dementia and Associated Risk Factors: A Population-Based Study in the Philippines

BACKGROUND

The Philippines is experiencing rapid demographic aging and with it, the dementia epidemic. Prevalence of dementia and associated risk factors have not been studied in the Philippines.

OBJECTIVES

The study aimed to provide a reliable estimate of dementia prevalence and identify associated risk factors in the Filipino population.

METHODS

1460 participants 60 years and older were randomly selected from the Marikina City's senior registry. A multidisciplinary team (nurse, psychologist, and neurologist) administered a comprehensive assessment to the study population: health history, neurological examination, Geriatric Depression Scale, Neuropsychiatric Inventory, Disability Assessment for Dementia, Alzheimer's Disease 8, and Clinical Dementia Rating Scale. The neurologist analyzed all clinical data to diagnose dementia based on the DSM-IV criteria, Alzheimer's Disease (AD) on the NINCDS-ADRDA criteria, vascular dementia (VaD) on the Hachinski Ischemic Scale, cognitive impairment no dementia (CIND) on a CDR score of 0.5 and not fulfilling DSM-IV criteria for dementia. Risk factors were correlated with dementia prevalence using multivariate binary logistic regression.

RESULTS

1460 persons were randomly selected. 1367 agreed to participate and underwent all assessments. The response rate was 93.6%. Dementia prevalence was found to be 10.6% (95% CI 9.0 to 12.4) with the breakdown 85.5% AD, 11.7% VaD, and 2.7% other dementias. In this population, 82.0% of men and 70.4% of women had at least one cardiovascular risk factor (hypertension, diabetes, dyslipidemia, smoking), which was associated with VaD prevalence but not AD.

CONCLUSION

The prevalence of dementia, CIND, and cardiovascular risk factors are high in the Philippines.

Protective preparation: a process central to family caregivers of persons with mild cognitive impairment

ABSTRACTBackground:To develop a theoretical model explaining the longitudinal changes in the caregiving process for family caregivers of persons with mild cognitive impairment (MCI) in Taiwan.

METHODS

A longitudinal, grounded theory approach using in-depth face-to-face interviews and an open-ended interview guide. We conducted 42 interviews over a two-year period; each participant was interviewed at least once every six months. All participants were interviewed in their home. The participants total of 13 family caregivers of persons with MCI.

RESULTS

One core theme emerged: "protective preparation." This reflected the family caregiving process of preparation for a further decline in cognitive function, and protection from the impact of low self-esteem, accidents, and symptoms of comorbidities for the family member with MCI. Protective preparation contained three components: ambivalent normalization, vigilant preparation, and protective management.

CONCLUSIONS

Interventions to help family caregivers manage the changes in persons with MCI can reduce caregiver burden. Our findings could provide a knowledge base for use by healthcare providers to develop and implement strategies to reduce caregiver burden for family caregivers of persons with MCI.

A Longitudinal Analysis of General Practitioner Service Use by Patients with Mild Cognitive Disorders in Australia

BACKGROUND

The aim of this study was to ascertain if participants diagnosed with any mild cognitive disorder (MCD) visited a general practitioner (GP) more than those without MCD and the effect of either depression or arthritis on GP use longitudinally.

METHODS

2,551 participants aged 60-64 years at baseline completed the Personality and Total Health Through Life (PATH) study in Canberra. Follow-up data were collected after 4 and 8 years. A cognitive screening battery was used to screen participants into a substudy of MCD.

RESULTS

Participants with any MCD had greater GP use than cognitively healthy participants across all three waves (wave 1, M = 7.35 vs. 5.59; wave 2, M = 7.77 vs. 5.86; wave 3, M = 9.01 vs. 6.81). After adjusting for demographic and health factors, MCD was a significant predictor of GP use at all three waves (p < 0.05, CI 0.84-0.99).

CONCLUSION

This study has shown that MCD is associated with a higher use of GP visits, especially if the patient has a comorbid condition.

Orthostatic hypotension associated with executive dysfunction in mild cognitive impairment

INTRODUCTION

Midlife hypertension is associated with dementia in longitudinal studies while chronic hypotension in the elderly is associated with dementia onset. Orthostatic hypotension could influence cognitive performance in the elderly. The objective of this study was to assess the relationship between orthostatic hypotension and cognitive functions.

METHODS

Consecutive participants with complete neuropsychological evaluation from a Memory Clinic were included. Orthostatic hypotension (OH) was defined by a fall≥20/10mmHg systolic/diastolic pressure. Participants were classified into one of 3 groups: 1) subjective cognitive impairment (SCI), 2) mild cognitive impairment (MCI), and 3) dementia. Neuropsychological tests were analyzed for patients with and without OH.

RESULTS

One hundred and twenty participants were included, of which 16 (13%) were classified as SCI, 42 (35%) as MCI, and 63 (52%) with dementia. Prevalence of OH was 0% for the SCI group, 26% (n=11) for the MCI group, and 38% (n=24) for the dementia group. Age, sex, education, and brief cognitive test scores (MMSE & MoCA) were not different between groups with or without OH. In the MCI group, OH was associated with lower cognitive performance in several executive functions tests: visual working memory (p<0.001), processing speed (p=0.006), Stroop flexibility (p=0.030) and Trail-Making Test part B (p=0.024). There was no difference in episodic memory performance. OH was associated with a diagnosis of hypertension and the use of antihypertensive medication. No differences were observed in vascular brain injury between groups with and without OH.

CONCLUSIONS

This study found that orthostatic hypotension prevalence is correlated to severity of cognitive deficits in a Memory Clinic. In MCI, OH is associated with lower performance in executive functions. OH could represent an under-recognized correlate of cognitive performance.

Distribution of Mini-Mental State Examination scores among urban community-dwelling older adults in Japan

OBJECTIVES

The Mini-Mental State Examination (MMSE) is widely used as a cognitive screening test for older adults; however, cognitive performance can be affected by age, education, and sample selection bias, including time and place. The aims of this study were to examine the distribution of scores on the Japanese version of the MMSE in an urban community sample and to provide normative data for older Japanese adults.

METHODS

A questionnaire survey was conducted on all residents aged 65 years and older living in an urban district in Tokyo (N = 7682). From among this population, 3000 residents were randomly selected to receive visits from trained nurses and to have their health status checked and their cognitive function examined using the MMSE.

RESULTS

Of the 2786 eligible residents, the MMSE was administered to 1341 (47%) and successfully completed by 1319 (mean age, 74.4 ± 6.4 years; mean years of formal education, 12.6 ± 2.9). The median score was 28. A total of 143 residents (10.8%) had scores below the traditional 23/24 cutoff point. Younger age and higher education were associated with better performance. Greater variation was seen among the oldest and least educated residents, especially among women.

CONCLUSION

The results of this study confirm that age and education affect MMSE scores. To ensure the effective use of the MMSE, it is recommended to examine scores corresponding to age and education. The normative data presented are expected to be useful for assessing MMSE scores in older individuals both in and out of the clinical setting. Copyright © 2016 John Wiley & Sons, Ltd.

Turmeric (Curcuma longa L.) extract may prevent the deterioration of spatial memory and the deficit of estimated total number of hippocampal pyramidal cells of trimethyltin-exposed rats

CONTEXT

Protection of neurons from degeneration is an important preventive strategy for dementia. Much of the dementia pathology implicates oxidative stress pathways. Turmeric (Curcuma longa L.) contains curcuminoids which has anti-oxidative and neuro-protective effects. These effects are considered to be similar to those of citicoline which has been regularly used as one of standard medications for dementia.

OBJECTIVE

This study aimed at investigating the effects of turmeric rhizome extract on the hippocampus of trimethyltin (TMT)-treated Sprague-Dawley rats.

MATERIALS AND METHODS

The rats were divided randomly into six groups, i.e., a normal control group (N); Sn group, which was given TMT chloride; Sn-Cit group, which was treated with citicoline and TMT chloride; and three Sn-TE groups, which were treated with three different dosages of turmeric rhizome extract and TMT chloride. Morris water maze test was carried out to examine the spatial memory. The estimated total number of CA1 and CA2-CA3 pyramidal cells was calculated using a stereological method.

RESULTS

The administration of turmeric extract at a dose of 200 mg/kg bw has been shown to prevent the deficits in the spatial memory performance and partially inhibit the reduction of the number of CA2-CA3 regions pyramidal neurons.

DISCUSSION

TMT-induced neurotoxic damage seemed to be mediated by the generation of reactive oxygen species and reactive nitrogen species. Turmeric extract might act as anti inflammatory as well as anti-oxidant agent.

CONCLUSIONS

The effects of turmeric extract at a dose of 200 mg/kg bw seem to be comparable to those of citicoline.

Relationship between lead exposure and mild cognitive impairment

INTRODUCTION

Since it is still controversial whether-low-to moderate long-term lead below current threshold values causes neurobehavioural deficits in adults.

METHODS

Forty lead-exposed workers subjects with a mean blood lead (PbB) level of 56.4 μg/dL and 40 non-lead-exposed aged matched subjects (PbB: 15.4 μg/dL) with the same socio-economic background were investigated. Participants were administered a neuropsychological tests consisting of BAMT (Branches Alternate Movements Task), FT (Finger Tapping Speed), DS (Digit Span) POMS (Profile of Mood States).

RESULTS

Authors noted a significant relationship between the exposed and the referent groups in tests mainly involving executive functions, short time memory and psycho-emotional variables. In addition, Poisson regression test performed on single psychoemotional factors (POMS), has allowed to evidence a significant influence of Pb e ZPP levels on tension, anxiety and depression.

CONCLUSIONS

The present study showed that lead exposure among adults at levels previously considered safe, results in impairment of certain cognitive abilities.

Dietary Intake of Nutrients and Lifestyle Affect the Risk of Mild Cognitive Impairment in the Chinese Elderly Population: A Cross-Sectional Study

Mild cognitive impairment (MCI) is a pre-clinical stage of Alzheimer’s disease afflicting a large number of the elderly throughout the world. However, modifiable risk factors for the onset and progression of MCI remain unclear. A cross-sectional study was performed to explore whether and how daily dietary nutrients intake and lifestyle impacted the risk of MCI in the Chinese elderly. We examined 2,892 elderly subjects, including 768 MCI patients and 2,124 subjects with normal cognition in three different Provinces of China. Dietary intake of nutrients were collected by using a 33-item food frequency questionnaire and calculated based on the Chinese Food Composition database. The MCI patients were first screened by Montreal Cognitive Assessment and then diagnosed by medical neurologists. Multivariate logistic regression and exploratory factor analyses were applied to identify and rank the risk factors. Three dietary nutrient intake combination patterns were identified as the major protective factors of MCI, with eigenvalues of 14.11, 2.26, and 1.51 and adjusted odds ratios (OR) of 0.77, 0.81, and 0.83 (P < 0.05), respectively. The most protective combination was featured with eight vitamins and six minerals, and OR for the third and fourth quartiles of these nutrients intake ranged from 0.48 to 0.74 (P < 0.05). Carotenoids, vitamin C, and vitamin B₆ exhibited the highest protective factor loadings of 0.97, 0.95, and 0.92 (P < 0.05), respectively. Education, computer use, reading, and drinking represented the most protective lifestyle factors (OR = 0.25 to 0.85, P < 0.05), whereas smoking and peripheral vascular diseases were associated with higher (OR = 1.40 and 1.76, P < 0.05) risk of MCI. Adequate dietary intake of monounsaturated fatty acids and cholesterol were significantly associated with decreased risk of MCI. In conclusion, adequate or enhanced intake of micronutrients seemed to lower the risk of MCI in the Chinese elderly. In addition, improving education and lifestyle such as reading, computer use and moderate drinking might also help to decrease the risk of MCI.

A Review of Risk Factors for Cognitive Impairment in Stroke Survivors

In this review, we aimed to identify the risk factors that may influence cognitive impairment among stroke survivors, namely, demographic, clinical, psychological, and physical determinants. A search from Medline, Scopus, and ISI Web of Science databases was conducted for papers published from year 2004 to 2015 related to risk factors of cognitive impairment among adult stroke survivors. A total of 1931 articles were retrieved, but only 27 articles met the criteria and were reviewed. In more than half of the articles it was found that demographical variables that include age, education level, and history of stroke were significant risk factors of cognitive impairment among stroke survivors. The review also indicated that diabetes mellitus, hypertension, types of stroke and affected region of brain, and stroke characteristics (e.g., size and location of infarctions) were clinical determinants that affected cognitive status. In addition, the presence of emotional disturbances mainly depressive symptoms showed significant effects on cognition. Independent relationships between cognition and functional impairment were also identified as determinants in a few studies. This review provided information on the possible risk factors of cognitive impairment in stroke survivors. This information may be beneficial in the prevention and management strategy of cognitive impairments among stroke survivors.

Living With Ambiguity: A Metasynthesis of Qualitative Research on Mild Cognitive Impairment

Purpose of the study:

Mild Cognitive Impairment (MCI) is a diagnosis proposed to describe an intermediate state between normal cognitive aging and dementia. MCI has been criticised for its conceptual fuzziness, its ambiguous relationship to dementia, and the tension it creates between medical and sociological understandings of “normal aging”.

Design and Methods:

We examined the published qualitative literature on experiences of being diagnosed and living with MCI using metasynthesis as the methodological framework.

Results:

Two overarching conceptual themes were developed. The first, MCI and myself-in-time, showed that a diagnosis of MCI could profoundly affect a person’s understanding of their place in the world. This impact appears to be mediated by multiple factors including a person’s social support networks, which daily activities are affected, and subjective interpretations of the meaning of MCI. The second theme, Living with Ambiguity, describes the difficulties people experienced in making sense of their diagnosis. Uncertainty arose, in part, from lack of clarity and consistency in the information received by people with MCI, including whether they are even told MCI is the diagnosis.

Implications:

We conclude by suggesting an ethical tension is always at play when a MCI diagnosis is made. Specifically, earlier support and services afforded by a diagnosis may come at the expense of a person’s anxiety about the future, with continued uncertainty about how his or her concerns and needs can be addressed.

Folates and aging: Role in mild cognitive impairment, dementia and depression

In almost all tissues, including the brain, folates are required for one-carbon transfer reactions, which are essential for the synthesis of DNA and RNA nucleotides, the metabolism of amino acids and the occurrence of methylation reactions. The aim of this paper is to review the impact of folate status on the risk of development of neuropsychiatric disorders in older individuals. The prevalence of folate deficiency is high among individuals aged ≥ 65 years mainly due to reduced dietary intake and intestinal malabsorption. Population-based studies have demonstrated that a low folate status is associated with mild cognitive impairment, dementia (particularly Alzheimer's disease) and depression in healthy and neuropsychiatric diseased older individuals. The proposed mechanisms underlying that association include hyperhomocysteinemia, lower methylation reactions and tetrahydrobiopterin levels, and excessive misincorporation of uracil into DNA. However, currently, there is no consistent evidence demonstrating that folic acid supplementation improves cognitive function or slows cognitive decline in healthy or cognitively impaired older individuals. In conclusion, folate deficiency seems to be an important contributor for the onset and progression of neuropsychiatric diseases in the geriatric population but additional studies are needed in order to increase the knowledge of this promising, but still largely unexplored, area of research.

Influence of socio-demographic features and apolipoprotein E epsilon 4 expression on the prevalence of dementia and cognitive impairment in a population of 70-74-year olds: the InveCe.Ab study

The age-specific prevalence rates of dementia vary widely. Studies focusing on specific age groups are needed to provide reliable estimates for healthcare providers and policy makers. We estimated the prevalence of dementia, dementia subtypes and cognitive impairment in "InveCe.Ab" (ClinicalTrials.gov, NCT01345110), a single-step multidimensional population-based study of 70-74-year olds living in Abbiategrasso (Milan, Italy). We also looked for associations with socio-demographic factors and the presence of the apolipoprotein E-ɛ4 allele. The overall dementia prevalence was 3% (95%CI: 2.1-4.1%) [Alzheimer's disease (AD): 1.2% (95%CI 0.6-1.9%); vascular dementia (VD): 1.4% (95%CI: 0.8-2.2%)]. Being single was found to be a risk factor for vascular dementia; subjects born in southern Italy were shown to be at greater risk both of overall dementia and of vascular dementia. The prevalence of cognitive impairment, with or without subjective cognitive complaints (cognitive impairment, no dementia, CIND) was 7.8% (95%CI: 6.4-9.4%). As regards the CIND subgroups, the prevalence of subjects with subjective cognitive complaints (mild cognitive impairment, MCI) was 5.0% (95%CI 3.9-6.3%), while the prevalence of those without MCI (CIND-other) was 2.8% (95%CI: 1.9-3.8). The males had a higher risk of MCI and CIND-other; the older subjects were more likely to have MCI, and those born in north-eastern Italy to have CIND-other. The prevalence of AD was higher among the apolipoprotein E-ɛ4 carriers. Our data highlight the importance of dementia and cognitive impairment in the transitional period from adulthood to old age, and reveal the presence of different associations with socio-demographic and genetic factors.

Brain aging and dementia during the transition from late adulthood to old age: design and methodology of the "Invece.Ab" population-based study

BACKGROUND

Developed countries are experiencing an unprecedented increase in life expectancy that is accompanied by a tremendous rise in the number of people with dementia. The purpose of this paper is to report on the study design and methodology of an Italian population-based study on brain aging and dementia in the elderly. This multi-domain study is structured in two phases. Our goal is to gather sufficient data to estimate the prevalence (phase I: cross-sectional study), the incidence and the progression of dementia and its subtypes as well as cognitive impairment (phase II: follow-up study) and to identify socio-demographic, clinical, and lifestyle factors associated with dementia and the quality of brain aging in people aged 70-74 years, a crucial point between late adulthood and old age.

METHODS/DESIGN

We chose to contact all 1773 people born between 1935-39 residing in Abbiategrasso, Milan, Italy. Those who agreed to participate in the "Invece.Ab" study were enrolled in a cross-sectional assessment and will be contacted two and four years after the initial data collection to participate in the longitudinal survey. Both the cross-sectional and longitudinal assessments include a medical evaluation, a neuropsychological test battery, several anthropometric measurements, a social and lifestyle interview, blood analyses, and the storage of a blood sample for the evaluation of putative biological markers.

DISCUSSION

Now at the end of the recruitment phase, the evaluable population has amounted to 1644 people. Among these, 1321 (80.35%) of the participants have completed phase I. This high return rate was likely due to the style of recruitment and personalization of the contacts.

Neural correlates of saccadic inhibition in healthy elderly and patients with amnestic mild cognitive impairment

Performance on tasks that require saccadic inhibition declines with age and altered inhibitory functioning has also been reported in patients with Alzheimer's disease. Although mild cognitive impairment (MCI) is assumed to be a high-risk factor for conversion to AD, little is known about changes in saccadic inhibition and its neural correlates in this condition. Our study determined whether the neural activation associated with saccadic inhibition is altered in persons with amnestic mild cognitive impairment (aMCI). Functional magnetic resonance imaging (fMRI) revealed decreased activation in parietal lobe in healthy elderly persons compared to young persons and decreased activation in frontal eye fields in aMCI patients compared to healthy elderly persons during the execution of anti-saccades. These results illustrate that the decline in inhibitory functions is associated with impaired frontal activation in aMCI. This alteration in function might reflect early manifestations of AD and provide new insights in the neural activation changes that occur in pathological ageing.

Pharmacological recommendations for the symptomatic treatment of dementia: the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia 2012

BACKGROUND

While there have been no new medications approved for the treatment of Alzheimer's disease (AD) or other dementias in Canada since 2004, the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD) reviewed and updated the clinical practice guidelines on the pharmacological management of dementia that were published previously.

METHODS

This review focused on the literature for the pharmacological treatment of dementia based on studies published since the third CCCDTD in 2006. A literature search of English-language medical databases was preformed for studies pertaining to the pharmacological treatment of AD and other dementias that examined the management of cognitive and functional impairment, as well as neuropsychiatric symptoms. All previous recommendations were reviewed, and only those that required updating based on new published studies were revised. Several new recommendations were also added. Recommendations were rated for quality of evidence and were approved by consensus.

RESULTS

There were 15 revised or new recommendations approved by consensus. The revised recommendations included acknowledging that cholinesterase inhibitors (ChEIs) possess a class effect and any of the agents can be used for AD across the spectrum of severity and with co-existing cerebrovascular disease. There was insufficient evidence to recommend for or against the use of ChEIs in combination with memantine for the primary indication of treating neuropsychiatric symptoms, or for the treatment of vascular dementia. Recommendations for the discontinuation of cognitive enhancers were revised and clarified, as well as the risks associated with discontinuing these drugs. ChEIs were recommended as a treatment option for dementia with Parkinson's disease. Risks associated with use of antipsychotics for neuropsychiatric symptoms were strengthened, and guidelines regarding the use of antidepressants for affective disturbances in dementia were weakened, and are now considered an option but not a firm recommendation. Valproate was recommended not to be used, and there was insufficient evidence to recommend for or against the use of selective serotonin reuptake inhibitors or trazodone for the treatment of agitation and aggression.

CONCLUSION

In spite of the lack of new therapeutic agents for the treatment of dementia, recent studies have helped to clarify and strengthen recommendations to optimize the pharmacological management of these illnesses.

Efficacy of a cognitive intervention program in patients with mild cognitive impairment

BACKGROUND

Mild cognitive impairment (MCI) is a transitional state between normal aging and dementia. Identifying this condition would allow early interventions that may reduce the rate of progression to Alzheimer's disease (AD). We examined the efficacy of a six-month cognitive intervention program (CIP) in patients with MCI and to assess patients' condition at one-year follow-up.

METHODS

Forty-six MCI participants assessed with neuropsychological, neurological, neuropsychiatry, and functional procedures were included in this study and followed up during a year. The sample was randomized into two subgroups: 24 participants (the "trained group") underwent the CIP during six months while 22 (control group) received no treatment. Sixteen participants dropped out of the study. The intervention focused on teaching cognitive strategies, cognitive training, and use of external aids, in sessions of two hours, twice per week for six months. Cognitive and functional measures were used as primary outcome and all were followed up at one year.

RESULTS

The intervention effect (mean change from baseline) was significant (p < 0.05) on the Mini-Mental State Examination (1.74), the Clinical Dementia Rating Scale (0.14), the Boston Naming Test (2.92), block design (-13.66), matrix reasoning (-3.07), and semantic fluency (-3.071) tasks. Four patients (one trained and three controls) progressed to dementia after one year of follow-up.

CONCLUSIONS

These results suggest that persons with MCI can improve their performance on cognitive and functional measures when provided with early cognitive training and it could persist in a long-term follow-up.

Increased masticatory activity and quality of life in elderly persons with dementia--a longitudinal matched cluster randomized single-blind multicenter intervention study

Background

Worldwide, millions of people are suffering from dementia and this number is rising. An index of quality of life (QoL) can describe the impact a disease or treatment has on a person’s wellbeing. QoL comprises many variables, including physical health and function, and mental health and function. QoL is related to masticatory ability and physical activity. Animal studies show that disruption of mastication due to loss of teeth or a soft diet leads to memory loss and learning problems. Since these are common complaints in dementia, it is hypothesized that improvement of masticatory function and normalization of diet consistency can increase QoL in elderly persons suffering from dementia. Therefore, the goal of the present study is to examine whether an increase in masticatory activity, achieved by increased food consistency and enhancement of masticatory function through improved oral health care has a positive effect on QoL, including cognition, mood, activities of daily living (ADL), and circadian rhythm in elderly persons with dementia.

Methods and design

The described study is a prospective longitudinal matched cluster randomized single-blind multicenter study. Participants are elderly persons living in the Netherlands, suffering from dementia and receiving psychogeriatric care. An intervention group will receive improved oral health care and a diet of increased consistency. A control group receives care as usual. Participants will be assessed four times; outcome variables besides QoL are cognition, mood, independence, rest-activity rhythm, blood pressure, and masticatory function.

Discussion

This research protocol investigates the effect of an intervention executed by daily caregivers. The intervention will increase masticatory activity, which is achieved by three different actions, (providing oral health care, increasing food consistency, or a combination of both). There is a certain amount of variety in the nature of the interventions due to local differences in nursing homes. This might be a scientific weakness in the study design; however, a practical implementation of any findings will be subject to the same factors, making this study design clinically relevant.

Trial registration

NTR1561

Alzheimer's disease dementia guidelines for diagnostic testing: a systematic review

Alzheimer's disease dementia (AD dementia) is one of the most common neurodegenerative diseases worldwide, with a growing incidence during the last decades. Clinical diagnosis of cognitive impairment and presence of AD biomarkers have become important issues for early and adequate treatment. We performed a systematic literature search and quality appraisal of AD dementia guidelines, published between 2005 and 2011, which contained diagnostic recommendations on AD dementia. We also analyzed diagnostic recommendations related to the use of brief cognitive tests, neuropsychological evaluation, and AD biomarkers. Of the 537 retrieved references, 15 met the selection criteria. We found that Appraisal of Guidelines Research and Evaluation (AGREE)-II domains such as applicability and editorial independence had the lowest scores. The wide variability on assessment of quality of evidence and strength of recommendations were the main concerns identified regarding diagnostic testing. Although the appropriate methodology for clinical practice guideline development is well known, the quality of diagnostic AD dementia guidelines can be significantly improved.

A review of multidomain interventions to support healthy cognitive ageing

OBJECTIVE

The risk for cognitive decline and for developing Alzheimer's disease increases with age. The aetiology is assumed to be of multi-factorial origin, and treatment opportunities are lacking. Despite the multi-factorial origin, many intervention studies focused on single factors to influence cognitive health with inconsistent findings. In this view, more and more intervention studies aim to intervene on multiple factors simultaneously to affect or slow down cognitive decline. The purpose of this paper is to give an overview of these multidomain intervention trials.

METHODS

We conducted a non-systematic literature search in Medline, Scopus, Cochrane Library, and clinical trials databases up to October 2011 to review multidomain interventions that investigated effects of combined lifestyle-related factors on cognitive decline and the progression of dementia.

RESULTS

Interest in multidomain interventions increased over the past years. We identified six completed and published trials and eight ongoing or not yet published studies that investigated effects on cognitive outcomes. First completed trials yielded promising results for the combination of exercise and mental training and diet and behavioural weight management. Results of ongoing multidomain trials are awaited.

CONCLUSIONS

Some evidence suggests that strategies which target multiple factors simultaneously may prove more effective than those focusing on a single mechanism or domain. Larger high-quality randomized controlled trials are required to systematically investigate the cognitive effect of programs comprising physical and mental activity as well as nutritional aspects.

A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine, GABAergic and opioid drugs

BACKGROUND

Mild cognitive deficits are experienced by 18% of community-dwelling older adults, many of whom do not progress to dementia. The effect of commonly used medication on subtle impairments in cognitive function may be under-recognized.

OBJECTIVE

The aim of the review was to examine the evidence attributing amnestic or non-amnestic cognitive impairment to the use of medication with anticholinergic, antihistamine, GABAergic or opioid effects.

METHODS

MEDLINE and EMBASE were searched for randomized, double-blind, placebo-controlled trials of adults without underlying central nervous system disorders who underwent detailed neuropsychological testing prior to and after oral administration of drugs affecting cholinergic, histaminergic, GABAergic or opioid receptor pathways. Seventy-eight studies were identified, reporting 162 trials testing medication from the four targeted drug classes. Two investigators independently appraised study quality and extracted relevant data on the occurrence of amnestic, non-amnestic or combined cognitive deficits induced by each drug class. Only trials using validated neuropsychological tests were included. Quality of the evidence for each drug class was assessed based on consistency of results across trials and the presence of a dose-response gradient.

RESULTS

In studies of short-, intermediate- and long-acting benzodiazepine drugs (n = 68 trials), these drugs consistently induced both amnestic and non-amnestic cognitive impairments, with evidence of a dose-response relationship. H(1)-antihistamine agents (n = 12) and tricyclic antidepressants (n = 15) induced non-amnestic deficits in attention and information processing. Non-benzodiazepine derivatives (n = 29) also produced combined deficits, but less consistently than benzodiazepine drugs. The evidence was inconclusive for the type of cognitive impairment induced by different bladder relaxant antimuscarinics (n = 9) as well as for narcotic agents (n = 5) and antipsychotics (n = 5). Among healthy volunteers >60 years of age, low doses of commonly used medications such as lorazepam 0.5 mg, oxybutynin immediate release 5 mg and oxycodone 10 mg produced combined deficits.

CONCLUSION

Non-amnestic mild cognitive deficits are consistently induced by first-generation antihistamines and tricyclic antidepressants, while benzodiazepines provoke combined amnestic and non-amnestic impairments. Risk-benefit considerations should be discussed with patients in order to enable an informed choice about drug discontinuation or substitution to potentially reverse cognitive adverse effects.

Recommendations of the 4th Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD4)

The 4th CCCDTD convened in May 2012 in Montreal with the primary aim of updating the previous diagnostic approach to AD, taking into account the revised diagnostic criteria proposed by the International Working Group (IWG) and the recommendations made by the National Institute on Aging-Alzheimer Association workgroups.