Disability in dementia: assessment, prevention, and rehabilitation

Assessing cognitive impairment and disability in older adults through the lens of whole brain white matter patterns

INTRODUCTION

This study aimed to explore the potential of whole brain white matter patterns as novel neuroimaging biomarkers for assessing cognitive impairment and disability in older adults.

METHODS

We conducted an in-depth analysis of magnetic resonance imaging (MRI) and amyloid positron emission tomography (PET) scans in 454 participants, focusing on white matter patterns and white matter inter-subject variability (WM-ISV).

RESULTS

The white matter pattern ensemble model, combining MRI and amyloid PET, demonstrated a significantly higher classification performance for cognitive impairment and disability. Participants with Alzheimer's disease (AD) exhibited higher WM-ISV than participants with subjective cognitive decline, mild cognitive impairment, and vascular dementia. Furthermore, WM-ISV correlated significantly with blood-based biomarkers (such as glial fibrillary acidic protein and phosphorylated tau-217 [p-tau217]), and cognitive function and disability scores.

DISCUSSION

Our results suggest that white matter pattern analysis has significant potential as an adjunct neuroimaging biomarker for clinical decision-making and determining cognitive impairment and disability.

HIGHLIGHTS

The ensemble model combined both magnetic resonance imaging (MRI) and amyloid positron emission tomography (PET) and demonstrated a significantly higher classification performance for cognitive impairment and disability. Alzheimer's disease (AD) revealed a notably higher heterogeneity compared to that in subjective cognitive decline, mild cognitive impairment, or vascular dementia. White matter inter-subject variability (WM-ISV) was significantly correlated with blood-based biomarkers (glial fibrillary acidic protein and phosphorylated tau-217 [p-tau217]) and with the polygenic risk score for AD. White matter pattern analysis has significant potential as an adjunct neuroimaging biomarker for clinical decision-making processes and determining cognitive impairment and disability.

Contribution of socioeconomic, lifestyle, and medical risk factors to disparities in dementia and mortality

Extensive literature in the United States documents racial/ethnic and gender disparities in the incidence and prevalence of dementia yet few studies have examined how race/ethnicity and gender intersect to shape inequalities in the risk of dementia. Moreover, few studies have examined heterogeneity in the contribution of known risk factors to dementia across these demographic strata while properly accounting for the semi-competing risk of death. I calculated the proportion of dementia cases attributable to socioeconomic, lifestyle, and medical risk factors across demographic subgroups using nationally representative data from the US-based Health and Retirement Study for the years 2000-2016 and a multistate framework that accounts for the semi-competing risk of death. Socioeconomic resources contributed to the largest number of dementia cases but the magnitude of this contribution varied across strata defined by race/ethnicity and gender. The greatest potential for dementia prevention was observed among non-Hispanic black and Hispanic men and women, supporting an intersectionality approach, and underscoring the need for culturally sensitive intervention and public health initiatives to address the growing burden of dementia. Taken together, work demonstrates the potential benefit of taking an intersectional approach to understanding disparities in dementia.

Multisensory Stimulation and Individualized Music Sessions on Older Adults with Severe Dementia: Effects on Mood, Behavior, and Biomedical Parameters

BACKGROUND

Multisensory stimulation and individualized music have shown to be good in handling the psychological and behavioral symptoms in people with severe dementia.

OBJECTIVE

Explore the effects of two nonpharmacological interventions, multisensory stimulation environment (MSSE) in a Snoezelen room and individualized music sessions, on mood, behavior, and biomedical parameters of institutionalized elderly patients with severe dementia.

METHODS

Randomized trial of 21 patients aged ≥65 years randomly assigned to two groups (MSSE and individualized music). Interventions administered in two-weekly sessions lasted 30 minutes for a period of 12 weeks. Main outcomes were recorded before, during, and at the end of the intervention.

RESULTS

Both groups had immediate positive effects on mood and behavior. Participants were more happy/more content (p < 0.001), talked more spontaneously (p = 0.009), related to people better (p = 0.002), were more attentive to/focused on their environment (p < 0.001), enjoyed themselves (p = 0.003), were less bored/inactive (p = 0.004), and more relaxed/content (p = 0.003). The MSSE group performed a better visual follow-up of the stimuli (p = 0.044), and the music group were more relaxed and happy (p = 0.003). A decrease in heart rate (p = 0.013) and an increase in oxygen saturation (p = 0.011) were observed from before to after interventions in both groups, with no significant differences between them.

CONCLUSIONS

Both interventions seem to be effective at managing mood and behavioral disturbances in the short term and at improving physiological rates, highlighting the efficacy of nonpharmacological treatments in patients with severe dementia.

Comparison of Methods for Algorithmic Classification of Dementia Status in the Health and Retirement Study

Supplemental Digital Content is available in the text.

Background:

Dementia ascertainment is time-consuming and costly. Several algorithms use existing data from the US-representative Health and Retirement Study (HRS) to algorithmically identify dementia. However, relative performance of these algorithms remains unknown.

Methods:

We compared performance across five algorithms (Herzog–Wallace, Langa–Kabeto–Weir, Crimmins, Hurd, Wu) overall and within sociodemographic subgroups in participants in HRS and Wave A of the Aging, Demographics, and Memory Study (ADAMS, 2000–2002), an HRS substudy including in-person dementia ascertainment. We then compared algorithmic performance in an internal (time-split) validation dataset including participants of HRS and ADAMS Waves B, C, and/or D (2002–2009).

Results:

In the unweighted training data, sensitivity ranged from 53% to 90%, specificity ranged from 79% to 97%, and overall accuracy ranged from 81% to 87%. Though sensitivity was lower in the unweighted validation data (range: 18%–62%), overall accuracy was similar (range: 79%–88%) due to higher specificities (range: 82%–98%). In analyses weighted to represent the age-eligible US population, accuracy ranged from 91% to 94% in the training data and 87% to 94% in the validation data. Using a 0.5 probability cutoff, Crimmins maximized sensitivity, Herzog–Wallace maximized specificity, and Wu and Hurd maximized accuracy. Accuracy was higher among younger, highly-educated, and non-Hispanic white participants versus their complements in both weighted and unweighted analyses.

Conclusion:

Algorithmic diagnoses provide a cost-effective way to conduct dementia research. However, naïve use of existing algorithms in disparities or risk factor research may induce nonconservative bias. Algorithms with more comparable performance across relevant subgroups are needed.

Assessment of cognition using surveys and neuropsychological assessment: the Health and Retirement Study and the Aging, Demographics, and Memory Study

OBJECTIVES

This study examines the similarity of cognitive assessments using 1 interview in a large population study, the Health and Retirement Study (HRS), and a subsample in which a detailed neuropsychiatric assessment has been performed (Aging, Demographics, and Memory Study [ADAMS]).

METHODS

Respondents are diagnosed in ADAMS as demented, cognitively impaired without dementia (CIND), or as having normal cognitive function. Multinomial logistic analysis is used to predict diagnosis using a variety of cognitive and noncognitive measures from the HRS and additional measures and information from ADAMS.

RESULTS

The cognitive tests in HRS predict the ADAMS diagnosis in 74% of the sample able to complete the HRS survey on their own. Proxy respondents answer for a large proportion of HRS respondents who are diagnosed as demented in ADAMS. Classification of proxy respondents with some cognitive impairment can be predicted in 86% of the sample. Adding a small number of additional tests from ADAMS can increase each of these percentages to 84% and 93%, respectively.

DISCUSSION

Cognitive assessment appropriate for diagnosis of dementia and CIND in large population surveys could be improved with more targeted information from informants and additional cognitive tests targeting other areas of brain function.

Functional impairment in elderly patients with mild cognitive impairment and mild Alzheimer disease

CONTEXT

The original mild cognitive impairment (MCI) criteria exclude substantial functional deficits, but recent reports suggest otherwise. Identifying the extent, severity, type, and correlates of functional deficits that occur in MCI and mild Alzheimer disease (AD) can aid in early detection of incipient dementia and can identify potential mechanistic pathways to disrupted instrumental activities of daily living (IADLs).

OBJECTIVES

To examine the number, type, and severity of functional impairments and to identify the clinical characteristics associated with functional impairment across patients with amnestic MCI (aMCI) and those with mild AD.

DESIGN

Study using baseline data from the Alzheimer's Disease Neuroimaging Initiative.

SETTING

Multiple research sites in the United States and Canada. Patients Samples included 229 control individuals, 394 patients with aMCI, and 193 patients with AD.

MAIN OUTCOME MEASURE

The 10-item Pfeffer Functional Activities Questionnaire (FAQ) assessed function.

RESULTS

Informant-reported FAQ deficits were common in patients with aMCI (72.3%) and AD (97.4%) but were rarely self-reported by controls (7.9%). The average severity per FAQ deficit did not differ between patients with aMCI and controls; both were less impaired than patients with AD (P < .001). Two FAQ items (remembering appointments, family occasions, holidays, and medications and assembling tax records, business affairs, or other papers) were specific (specificity estimate, 0.95) in differentiating the control group from the combined aMCI and AD groups (only 34.0% of patients with aMCI and 3.6% of patients with AD had no difficulty with these 2 items). The severity of FAQ deficits in the combined aMCI and AD group was associated with worse Trail Making Test, part A scores and smaller hippocampal volumes (P < .001 for both). Within the aMCI group, functionally intact individuals had greater hippocampal volumes and better Auditory Verbal Learning Test 30-minute delay and Trail Making Test, part A (P < .001 for each) scores compared with individuals with moderate or severe FAQ deficits. Patients with a high number of deficits were more likely to express the apolipoprotein ε4 allele (63.8%) compared with patients with no (46.8%) or few (48.4%) functional deficits.

CONCLUSIONS

Mild IADL deficits are common in individuals with aMCI and should be incorporated into MCI criteria. Two IADLs--remembering appointments, family occasions, holidays, and medications and assembling tax records, business affairs, or other papers--appear to be characteristic of clinically significant cognitive impairment. In patients with aMCI, impairment in memory and processing speed and greater medial temporal atrophy were associated with greater IADL deficits.

The measurement of everyday cognition (ECog): scale development and psychometric properties

This article describes the development and validation of an instrument to assess cognitively mediated functional abilities in older adults, Everyday Cognition (ECog). The ECog is an informant-rated questionnaire comprised of multiple subscales. Confirmatory factor analysis (CFA) was used to examine its factor structure. Convergent validity was evaluated by comparing it to established measures of everyday function. External validity was evaluated by comparing ECog results across different clinical groups [cognitively normal, mild cognitive impairment (MCI), dementia]. CFA supported a seven-factor model including one global factor and six domain-specific factors (Everyday Memory, Language, Visuospatial Abilities, Planning, Organization, and Divided attention). The ECog correlated with established measures of functional status and global cognition, but only weakly with age and education. The clinical groups performed differently in each domain. In addition to the global factor, the Everyday Memory factor independently differentiated MCI from Normal, while the Everyday Language domain differentiated Dementia from MCI. Different subtypes of MCI also showed different patterns. Results suggest the ECog shows promise as a useful tool for the measurement of general and domain-specific everyday functions in the elderly.

[Cross-cultural adaptation of the Disability Assessment for Dementia (DAD)]

The original version of the Disability Assessment for Dementia (DAD) was translated into Portuguese and back translated to English. The divergences of translation were identified and discussed, resulting in a version that was used in a preliminary investigation for cross-cultural adaptation. The final version was administered to 29 patients with mild to moderate probable Alzheimer's disease. The correlation coefficients of DAD were 0.929 and 0.932 for the inter-examiner and test-retest evaluations respectively. The reliability indexes were also high (Kappa 0.72 p<0.001 inter-examiners and 0.85 p<0.001 test-retest). The Brazilian version of DAD was easy to administer and had good reliability to assess the functional status of demented patients. It will contribute to the follow-up of these patients in our population. Moreover, it can be used in transcultural studies on functional abilities in dementia.

Perspective taking to assess self-personality: what's modified in Alzheimer's disease?

Personality changes are frequently described by caregivers of patients with Alzheimer's disease, while they are less often reported by the patients. This relative anosognosia of Alzheimer disease (AD) patients for personality changes might be related to impaired self-judgment and to decreased ability to understand their caregiver's perspective. To investigate this issue, we explored the cerebral correlates of self-assessment and perspective taking in patients with mild AD, elderly and young volunteers. All subjects assessed relevance of personality traits adjectives for self and a relative, taking either their own or their relative's perspective, during a functional imaging experiment. The comparison of subject's and relative's answers provided congruency scores used to assess self-judgment and perspective taking performance. The self-judgment "accuracy" score was diminished in AD, and when patients assessed adjectives for self-relevance, they predominantly activated bilateral intraparietal sulci (IPS). Previous studies associated IPS activation with familiarity judgment, which AD patients would use more than recollection when retrieving information to assess self-personality. When taking a third-person perspective, patients activated prefrontal regions (similarly to young volunteers), while elderly controls recruited visual associative areas (also activated by young volunteers). This suggests that mild AD patients relied more on reasoning processes than on visual imagery of autobiographical memories to take their relative's perspective. This strategy may help AD patients to cope with episodic memory impairment even if it does not prevent them from making some mind-reading errors.

[The Geriatric Day-Care assistance mode: functional effects in a six month multidisciplinary health care program]

The objective is to describe the functional capacity of elderly patients who took part in a six-month follow-up program at a geriatric day care center. The methods used were a six-month observation clinical study. The following tools were used to assess fourteen elderly patients over 80 years old at admission at the day care and for six months thereafter: Brazilian OARS Multidimensional Functional Assessment Questionnaire (daily life activities), Mini-Mental State Exam (cognition), Berg Balance Scale (functional balance evaluation) and Timed Up and Go Test (mobility). Data were analyzed using descriptive statistics and Wilcoxon and paired-samples T tests to verify statistical differences over time, a=0.05. The results showed significant differences between assessment and reassessment of the global functional capacity scores (p=0.019) and postural transfer balance-related ability (p=0.041), showing improvement over time. After follow-up, scores related to the other variables remained unchanged.

CONCLUSION

multidisciplinary health care at the geriatric day care center reinforced improvements or maintenance of the participants functional capacities, proving to be a promising alternative health care mode for the elderly.

Evaluating elements of executive functioning as predictors of instrumental activities of daily living (IADLs)

OBJECTIVE

Executive functioning has been repeatedly linked to the integrity of instrumental activities of daily living (IADL). The present study examined the association of multiple executive functioning elements (i.e., working memory, generation, inhibition, planning, and sequencing) to IADLs among an older adult cohort at risk for future cognitive and functional decline.

METHODS

Seventy-two participants with prevalent but stable cardiovascular disease completed a neuropsychological protocol assessing multiple elements of executive functioning, including COWA, PASAT, DKEFS Color-Word Interference Test, DKEFS Trail-Making Test, DKEFS Tower Test, and Ruff Figural Fluency Test. Reliable informants completed a measure of IADLs.

RESULTS

Stepwise logistic regression selected a model involving a single significant predictor, a measure of inhibition (i.e., DKEFS Color-Word Interference Test), which had a significant regression coefficient. Subsequent correlation analyses confirmed an association between the inhibition measure and multiple IADL items. Inter-item comparisons among the IADLs revealed significant differences, such that telephone use and laundry were significantly more intact than most other IADLs while shopping and housekeeping were most compromised.

CONCLUSIONS

Our data suggest that inhibition, also known as susceptibility to interference, is most strongly related to IADL impairment among patients at risk for future cognitive and functional decline.

Knowledge and lifestyle behaviors of healthy older adults related to modifying the onset of vascular dementia

The purpose of this study was to examine the relationship between knowledge and practice of lifestyle behaviors in healthy older adults related to the prevention of vascular dementia. Data were derived from a convenience sample of 281 Canadian participants 55 years of age and older. Lifestyle was measured using the health-promoting lifestyle profile (HPLP). Seven knowledge sub-scales were developed consistent to the HPLP. Multivariate analysis found that four independent variables accounted for 26% of the variance of a healthy lifestyle score and included those who reported a lower level of stress, indicated a higher knowledge of interpersonal relations, had a better general health self-assessment and higher medical knowledge. These Canadian results were compared with those from a study conducted in Australia and found to be similar. The study argues that health professionals and health education programs can better promote and increase awareness of healthy lifestyle behaviors by assisting older adults to apply this knowledge in their daily lives. Specifically, the study discusses policy and practice implications with regards to lifestyle issues relating to health responsibility, physical activity, spirituality, stress management, interpersonal relationships and nutrition.

Bedingungen der Erhaltung und Förderung von Selbst- ständigkeit im höheren Lebensalter (SIMA)

Zusammenfassung: Im Rahmen der 1991 begonnenen Längsschnittstudie SIMA wurde die Entwicklung einer demenziellen Erkrankung unter den Teilnehmern zwischen 1991 und 1998 verfolgt. Für insgesamt 340 der ursprünglich 375 Teilnehmer ließ sich feststellen, ob bei ihnen bis Ende 1998 eine demenzielle Erkrankung aufgetreten ist. Die Teilnehmer lebten bei Studienbeginn selbstständig und waren zwischen 75 und 93 Jahren bzw. im Mittel 79.5 (± 3.5) Jahre alt. Unter Einschluss der inzwischen verstorbenen Teilnehmer erkrankten 46 Teilnehmer an einer Demenz. Weitere 28 Teilnehmer litten an einer leichten kognitiven Beeinträchtigung. In multivariaten Risikoanalysen (Cox Regression) wurden signifikante medizinische und psychologische Risikofaktoren bestätigt, wobei es sich auf der medizinischen Seite jeweils um Diagnosen, auf der psychologischen Seite um Leistungen unter dem Median der Gesamtgruppe handelte. Als die bedeutendsten Demenzrisiken ließen sich verschiedene geringe kognitive Leistungen und das Auftreten einer Frühsymptomatik erkennen. Die Befunde der SIMA-Studie zeigen, dass weder Defizite in einem einzelnen kognitiven Leistungsbereich noch einzelne typische Erkrankungen die ausschließlichen Demenzrisiken im höheren Lebensalter darstellen. Die gleichzeitige Bedeutung insbesondere einer Reihe kognitiver Risikofaktoren dokumentiert zudem, dass der Beginn einer Demenz möglicherweise durch ein multimodales Trainingsprogramm erfolgreich hinausgezögert werden kann.

Bedingungen der Erhaltung und Förderung von Selbstständigkeit im höheren Lebensalter (SIMA)

Zusammenfassung: Im Rahmen der 1991 begonnenen Längsschnittstudie SIMA wurde die Entwicklung der Selbstständigkeit der Teilnehmer zwischen 1991 und 1998 verfolgt. Für insgesamt 340 der ursprünglich 375 Teilnehmer ließ sich bis Ende 1998 der Status im Hinblick auf Unselbstständigkeit, Demenz und Mortalität ermitteln. Die Teilnehmer lebten bei Studienbeginn selbstständig und waren zwischen 75 und 93 Jahren bzw. im Mittel 79,5 ± 3,5 Jahre alt. In multivariaten Risikoanalysen (Cox Regression) wurden signifikante medizinische und psychologische Risikofaktoren bestätigt. Als hoch signifikante Unselbstständigkeitsrisiken erwiesen sich Apoplex, Depression, eine submediane subjektive Bewertung der Befindlichkeit sowie spezifische Gedächtnisdefizite. Als bedeutendste Demenzrisiken ließen sich verschiedene kognitive Leistungsdefizite und das Vorliegen einer Frühsymptomatik identifizieren. Die höchsten Zusammenhänge mit der Mortalität wiesen Rauchen, Diabetes mellitus sowie jeweils eine subjektive Bewertung der Gesundheit und eine körperliche Leistungsfähigkeit unter dem Gruppenmedian auf. Die Befunde der SIMA-Studie zeigen, dass weder eine hohe Multimorbidität noch einzelne typische Erkrankungen die ausschließlichen Unselbstständigkeits-, Demenz- oder Mortalitätsrisiken im höheren Lebensalter darstellen. Die gleichzeitige Bedeutung psychologischer Risikofaktoren, z. B. von Einschränkungen in der Befindlichkeit oder Defiziten in visuellen Gedächtnisleistungen bzw. der kognitiven Geschwindigkeit, sowie eines Mangels an körperlichen Aktivitäten dokumentiert zudem, dass einer Unselbstständigkeit und möglicherweise auch einer Demenz durch ein multimodales Trainingsprogramm erfolgreich begegnet werden kann.

[Cognitive rehabilitation in Alzheimer's disease patients: multidisciplinary team report]

OBJECTIVE

This study aims to show preliminary results of the 'combined treatment' (acetylcholinesterase inhibitor + cognitive training) on a group of mild Alzheimer's disease (AD) patients, followed-up for 7 months.

METHODS

Six mild AD patients, diagnosed according to ICD-10 and NINCDS-ADRDA criteria, were included on a open trial with Rivastigmine, 6-12 mg/day, for 2 months, followed by a weekly cognitive rehabilitation group, for 5 months. Caregivers were submitted to a weekly group of counseling and support for 5 months.

RESULTS

Stabilization or mild improvement of patients' cognitive and activities of daily living deficits were found, besides reduction of patients and caregivers' depressive and anxiety levels.

CONCLUSION

The 'combined treatment' can help on the stabilization or result on a mild improvement of AD patients' cognitive and functional deficits. Support and counseling interventions can reduce the levels of caregivers' psychiatric symptoms.

Cognitive and motor impairments predict functional declines in patients with vascular dementia

BACKGROUND

Vascular dementia (VaD) is associated with impairments in cognitive, motor, and functional domains. Patients with VaD display diverse cognitive and motor deficits, however, and relationships between these impairments and independent living abilities remain unclear.

OBJECTIVES

The purpose of the present study was to investigate the contributions made by attentional/executive and motor functions in the prediction of basic and instrumental activities of daily living in 32 patients with VaD. We hypothesized that: (a) motor abilities would emerge as a significant predictor of basic activities of daily living, whereas attentional/executive abilities would not, and (b) both motor and attentional/executive abilities would emerge as significant predictors of instrumental activities of daily living.

RESULTS

Stepwise regression analyses revealed that motor performance, but not attentional/executive abilities, accounted for a significant proportion of the variance in basic activities of daily living, and that both motor and attentional/executive abilities contributed significantly to the prediction of instrumental activities of daily living.

CONCLUSIONS

These results suggest that attentional/executive and motor impairments may underlie specific aspects of functional disability among patients with VaD.

Older people's knowledge and practice about lifestyle behaviors that may prevent vascular dementia

This study examined the relationship between knowledge and practice of healthy lifestyle behaviors in the prevention of vascular dementia. Data presented here are derived from a convenience sample of 296 participants recruited through senior citizen agencies in Australia. Lifestyle was measured using the Health-promoting Lifestyle Profile (HPLP). Seven knowledge subscales were developed, consistent with the HPLP. Data were analyzed using multiple regression analysis. Correlations among the lifestyle and knowledge indicated statistically significant results. However, the strength of these associations was generally weak. Multivariate analysis found that six variables explained 20% of the variance in the lifestyle score. These included: knowledge of interpersonal relations, knowledge of physical activity, medical knowledge, medical history, self-assessment of general health, and use of alcohol. The results indicate that knowledge, by itself, does not necessarily ensure that people engage in self-practising healthy lifestyle behaviors, and those who experience illness and, perhaps exposure to risk factors, had higher HPLP scores. Recommendations for how older people can be supported to reduce some of the attitudinal barriers that reduce healthy lifestyle behaviors are discussed.

Management of problematic behavioral symptoms associated with dementia: a cognitive developmental approach

The purpose of this 3-year study was to test the efficacy of using a theoretical model based on Piaget's cognitive developmental stages for consistent behavioral and environmental interventions for persons at all stages of Alzheimer's disease and related disorders (ADRD) in nursing home and special care units. The specific aims were to reduce problematic behavioral symptoms and the number, amount and frequency of use of psychotropic medications. After 18 months, problem behaviors and some types of psychotropic medications significantly decreased in the treatment group but not in the control group. Results of the study indicate that using behavioral and environmental interventions based on Piaget levels of cognitive development may be an effective method of managing problematic behavioral symptoms and decreasing the use of psychotropic medications in institutionalized ADRD patients.

Differential diagnosis of dementia. The clinical process

Dementia as a syndrome must be differentiated from nondementing conditions. Dementia itself must also be differentiated as to cause, as in certain cases reversible conditions may be responsible. This article examines the clinical process of such differentiation, providing a decision free for diagnosis and a summarizing algorithm for thinking through individual cases, with a focus on the most frequent cause of dementia, Alzheimer's disease. Also outlined are the stages of Alzheimer's disease, with the admonition that variations from the expected progression may represent a dementia diagnosis other than Alzheimer's disease or the co-occurrence of some other contributing factors.