Behavioral and Psychological Symptoms of Dementia as a Means of Communication: Considerations for Reducing Stigma and Promoting Person-Centered Care

Dementia patients in palliative care according to data from the German National Hospice and Palliative Care Register (2009-2021)

BACKGROUND

People with dementia are less in focus of palliative care research than other patient groups even though the awareness of their palliative and end-of-life care needs is rising. Empirical data analyses on people with dementia in palliative care services are lacking.

AIM

To explore the prevalence of dementia diagnoses as per the ICD criteria among users of various palliative care settings and to compare use of palliative services, care pathways, and outcomes in people with and without a dementia diagnosis.

DESIGN

We conducted retrospective analysis of dementia diagnoses as per ICD (F00-F03/G30) in the German National Hospice and Palliative Care Register between 2009 and 2021. The analysis used methods of descriptive and inferential statistics, including the Bonferroni correction for alpha error inflation.

SETTING/PARTICIPANTS

We limited the analysis to the subsample of people aged over 64.

RESULTS

The prevalence of dementia in the different settings of palliative care was lower than in the age-comparable population: Of the 69,116 data sets included in the analysis, a small minority (3.3%) was coded with dementia as the principal diagnosis. Among patients on inpatient palliative care wards, 0.8% (148 of 19,161) had a dementia diagnosis, as did 2.2% (52 of 2,380) of those under hospital palliative care support teams and 4.3% (2,014 of 46,803) of those receiving specialized palliative care at home.

CONCLUSIONS

The records of the German National Hospice and Palliative Care Register suggest that the prevalence of dementia is lower than one might expect from general population data, though numbers are in line with international studies on proportion of dementia patients receiving palliative care. Future research could usefully examine whether this discrepancy stems either from omissions in coding dementia as patients' principal diagnosis respectively from lapses in documentation of a dementia diagnosis previously made, or from barriers to accessing palliative care services or even displays being excluded from palliative care when trying to access it.

TRIAL REGISTRATION

No registration.

Dignity in people with dementia: A concept analysis

Background: Dignity, an abstract and complex concept, is an essential part of humanity and an underlying guiding principle in healthcare. Previous literature indicates dignity is compromised in people with dementia (PwD), but those PwD maintain the capacity to live with dignity with appropriate external support. Alzheimer's disease and related dementias (ADRDs) lead to progressive functional decline and increased vulnerability and dependence, leading to heightened risks of PwD receiving inappropriate or insufficient care that diminishes dignity. Considering the increased disease prevalence and the continuously escalating costs of dementia care, establishing a productive value-based guideline may prevent suffering, maximize dignity, and thus promote quality of life (QoL).Aim: The goal of this project is to identify actionable targets for integrating dignity harmoniously and practically into care planning and management for PwD.Research Design: We conducted a concept analysis using Walker and Avant's eight-step process. A comprehensive literature search was conducted (PubMed and CINAHL) with the keywords "dignity," "dementia," "Alzheimer's disease," and "dementia care."Results: A total of 42 out of 4910 publications were included. The concept of dignity in PwD is operationalized as the promotion of worthiness and the accordance of respect that allows the presence and expression of a person's sense of self, regardless of physical, mental, or cognitive health. The concept has two subdimensions: absolute dignity which encompasses the inherent self and relative dignity characterized by its dynamic reflective nature. Worthiness and respect are the two main attributes, while autonomy is an underlying component of dignity. Specific antecedents of dignity in PwD are empowerment, non-maleficence, and adaptive environmental scaffolding. As a consequence of facilitating dignity in PwD, QoL may be enhanced.Conclusion: As a foundational and necessary humanistic value, incorporating dignity into dementia care can lead to efficient and effective care that optimizes QoL in PwD throughout their disease progression.

Is there evidence for using ketamine among individuals with dementia?

The aim of this short narrative review was to evaluate the existing literature regarding the clinical use of ketamine among individuals with dementia, especially those with behavioral disturbances. PubMed, Cochrane, and Ovid (Embase, APA PsycINFO, and MEDLINE) databases were searched for abstracts using the search terms "ketamine" AND "dementia." Only articles describing the use of ketamine in individuals with dementia were included. Articles that did not include individuals with dementia, did not use ketamine, were published in a non-English language, primarily described animal studies, or were reviews were excluded. Three case reports met the inclusion criteria. One described the use of subcutaneous ketamine for depression, one described the use of intramuscular ketamine for acute agitation, and one described the use of S-ketamine as anesthesia during electroconvulsive therapy for depression and catatonia. No significant adverse effects were reported in any of the cases. Although the use of ketamine in the treatment of depression and agitation associated with dementia has potential, the current evidence remains limited. High-quality prospective studies are needed to confirm the observations of these case reports before ketamine can be used to treat behavioral disturbances in individuals with dementia.

Horticultural Therapy for Individuals Coping with Dementia: Practice Recommendations Informed by Related Non-Pharmacological Interventions

Dementia care currently presents a challenge to healthcare providers on many levels. The rapid increase in the number of people with dementia and the costs of care certainly contribute to these challenges. However, managing the behavioral and psychological symptoms of dementia (BPSDs) has become one of the most significant tasks in providing care and can lead to poor health and well-being outcomes, not only for the people living with dementia (PLWD) but also for those providing their care. Cost-effective, easily implemented, highly adaptable, empirically based alternatives are needed. Interventions such as Horticultural Therapy (HT), which is naturally informed by Montessori-Based Methods for Dementia and sensory reminiscence therapies, meets these qualifying factors. This article, based on a review of current best practices and clinical experience, hopes to provide recommendations for such an intervention along with special considerations for PLWD and adaptations for different acuity levels. With additional safe and effective, person-centered, non-pharmacological interventions available for the complex cognitive and neuropsychiatric manifestations of this disease, a better care milieu can be provided, improving the quality of life for both patients and caregivers. This article also identifies the need for continued research into the synergistic effects of person-centered behavioral and psychosocial interventions combined with environmental approaches to provide the optimal healing environment for those coping with dementia.

Topical Cellular/Tissue and Molecular Aspects Regarding Nonpharmacological Interventions in Alzheimer's Disease-A Systematic Review

One of the most complex and challenging developments at the beginning of the third millennium is the alarming increase in demographic aging, mainly-but not exclusively-affecting developed countries. This reality results in one of the harsh medical, social, and economic consequences: the continuously increasing number of people with dementia, including Alzheimer's disease (AD), which accounts for up to 80% of all such types of pathology. Its large and progressive disabling potential, which eventually leads to death, therefore represents an important public health matter, especially because there is no known cure for this disease. Consequently, periodic reappraisals of different therapeutic possibilities are necessary. For this purpose, we conducted this systematic literature review investigating nonpharmacological interventions for AD, including their currently known cellular and molecular action bases. This endeavor was based on the PRISMA method, by which we selected 116 eligible articles published during the last year. Because of the unfortunate lack of effective treatments for AD, it is necessary to enhance efforts toward identifying and improving various therapeutic and rehabilitative approaches, as well as related prophylactic measures.

Exploring why "memory loss" is a misleading descriptor of people living with dementia and can lead to dysfunctional care

Amidst goals for prevention and improved treatment for people living with dementia, much remains needed to enhance the quality of life of those currently diagnosed, especially the transfer of accurate information from professionals to the public. Although many healthcare professionals understand the various types of memory and which are likely to be more affected than others during the progression of dementia, lay persons are more frequently unaware of that important information. The terms used to describe the symptoms of dementia can have a great impact on perceptions of faculties that are absent, compromised, or preserved. Understanding the nuances of preserved memory faculties and other cognitive abilities retained by persons with dementia is important in this regard. The term "memory loss" as a descriptor of the syndrome of dementia and ascribing it to persons with dementia connotes an inability to form new memories and participate in meaningful social interactions, which is detrimental to their personhood. From a multidisciplinary approach drawn from neurology, neurobiology, psychology, and case vignettes, we aim herein to highlight the ways in which the term "memory loss" can be inaccurate, counterproductive and potentially promote dementia-related misperceptions, malignant positioning and malignant social psychology. Persons with dementia unequivocally struggle with explicit memory, or recalling on demand, but retain implicit memory, as evidenced by research and everyday actions. Therefore, we propose the use of alternative medical language to reflect accurately memory impairment and preservation of some important memory capabilities.

Association between serum globulin and cognitive impairment in older American adults

Background and aims

Cognitive impairment is on the rise around the world, with profound economic and social consequences. Serum globulin, a marker of liver function, may also play a role in cognitive function. Unfortunately, no consistent conclusion exists regarding the association between serum globulin and cognitive function.

Methods

Data from the 2011 to 2014 National Health and Nutrition Examination Survey were used to assess the association between serum globulin and cognitive impairment. Cognitive function was assessed by three tests: Consortium to Establish a Registry for Alzheimer's Disease (CERAD), Animal Fluency (AF), and Digit Symbol Substitution Test (DSST). Furthermore, the breakthrough point of cognitive impairment correlated with CERAD < 5, AF < 14, and DSST < 34. A weighted multiple logistics regression model was used to verify the association between serum globulin and cognitive impairment. Generalized additive models (GAMs) and a smooth curve fit (penalty spline method) were used to determine a non-linear relationship between serum globulin and cognitive impairment. Finally, subgroup analysis and interaction tests were conducted to further verify the association between serum globulin and cognitive impairment.

Results

Data from 2,768 participants aged ≥60 (in accordance with the study design) were collected for the final analysis. Data suggested that serum globulin levels were associated with an elevated cognitive impairment based on the AF [full adjustment, OR = 1.05, 95% CI: 1.01-1.08] and DSST [full adjustment, OR = 1.06, 95% CI: 1.02-1.10] tests. Eventually, the GAM and smooth curve fit model was conducted to confirm that the association between serum globulin and cognitive impairment was non-linear. Moreover, the inflection point was 27 g/L serum globulin based on the CERAD test and 35 g/L serum globulin based on the AF test. Finally, the interaction term between serum globulin and cognitive impairment based on the AF test indicated no significant interactions among all variables (all p for interaction >0.05).

Conclusion

The association between serum globulin levels and cognitive impairment is non-linear. A threshold effect exists between serum globulin and cognitive impairment. Large-scale prospective clinical trials are needed to validate our findings.

Generation and Characterization of the First Murine Model of Alzheimer's Disease with Mutated AβPP Inserted in a BALB/c Background (C.B6/J-APPswe)

BACKGROUND

Numerous mouse models of Alzheimer's disease (AD) are available, but all suffer from certain limitations, thus prompting further attempts. To date, no one model exists with amyloidopathy in a BALB/c strain.

OBJECTIVE

To generate and characterize the C.B6/J-APPswe mouse, a model of AD with a mutated human gene for the amyloid-β protein precursor (AβPP) inserted in a BALB/c background.

METHODS

We analyzed five groups at different ages (3, 6, 9, 12, and 16-18 months) of C.B6/J-APPswe and wild-type mice (50% males and 50% females) for the main hallmarks of AD by western blotting, amyloid-β (Aβ) ELISA, immunocytochemistry, electrophysiology, and behavioral tests.

RESULTS

The C.B6/J-APPswe mouse displays early AβPP and Aβ production, late amyloid plaques formation, high level of tau phosphorylation, synaptic deficits (reduced density and functional impairment due to a reduced post-synaptic responsiveness), neurodegeneration caused by apoptosis and necroptosis/necrosis, microgliosis, astrocytic abnormalities, and sex-related differences in explorative behavior, anxiety-like behavior, and spatial long-term and working memories. Social housing is feasible despite the intra-cage aggressiveness of male animals.

CONCLUSION

C.B6/J-APPswe mice develop most of the distinctive features of AD and is a suitable model for the study of brain atrophy mechanisms and of the differences between males and females in the onset of cognitive/non-cognitive deficits.

"The Sun Came Up Because You Got Here…": A Qualitative Exploration of Person-Centered Care Strategies Used by Adult Day Care Centers to Manage Behavioral and Psychological Symptoms of Dementia

In order to reduce care partner strain and support aging in place for people living with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), adult day centers (ADCs) must manage behavioral and psychological symptoms of dementia (BPSD). The purpose of this paper is to identify person-centered care strategies used by center staff to manage BPSD. Six focus groups with center staff (n = 31) were conducted. Data were analyzed using directed content analysis guided by Kitwood's conceptual approach to cultivating personhood in dementia care. Themes were identified and organized within Kitwood's framework. The results demonstrate that staff incorporate evidence-based person-centered approaches to AD/ADRD care that align with Kitwood's principles of comfort, attachment, inclusion, and identity. Staff individualize their approach to people with AD/ADRD within a group setting. They monitor, engage, socially stimulate, and, when needed, de-stimulate them. Centers are flexible social environments with underrecognized expertise managing BPSD using person-centered approaches.

Studies on the mechanism of Toxoplasma gondii Chinese 1 genotype Wh6 strain causing mice abnormal cognitive behavior

BACKGROUND

Alzheimer's disease presents an abnormal cognitive behavior. TgCtwh6 is one of the predominant T. gondii strains prevalent in China. Although T. gondii type II strain infection can cause host cognitive behavioral abnormalities, we do not know whether TgCtwh6 could also cause host cognitive behavioral changes. So, in this study, we will focus on the effect of TgCtwh6 on mouse cognitive behavior and try in vivo and in vitro to explore the underlying mechanism by which TgCtwh6 give rise to mice cognitive behavior changes at the cellular and molecular level.

METHODS

C57BL/6 mice were infected orally with TgCtwh6 cysts. From day 90 post-infection on, all mice were conducted through the open field test and then Morris water maze test to evaluate cognitive behavior. The morphology and number of cells in hippocampus were examined with hematoxylin-eosin (H&E) and Nissl staining; moreover, Aβ protein in hippocampus was determined with immunohistochemistry and thioflavin S plaque staining. Synaptotagmin 1, apoptosis-related proteins, BACE1 and APP proteins and genes from hippocampus were assessed by western blotting or qRT-PCR. Hippocampal neuronal cell line or mouse microglial cell line was challenged with TgCtwh6 tachyzoites and then separately cultured in a well or co-cultured in a transwell device. The target proteins and genes were analyzed by immunofluorescence staining, western blotting and qRT-PCR. In addition, mouse microglial cell line polarization state and hippocampal neuronal cell line apoptosis were estimated using flow cytometry assay.

RESULTS

The OFT and MWMT indicated that infected mice had cognitive behavioral impairments. The hippocampal tissue assay showed abnormal neuron morphology and a decreased number in infected mice. Moreover, pro-apoptotic proteins, as well as BACE1, APP and Aβ proteins, increased in the infected mouse hippocampus. The experiments in vitro showed that pro-apoptotic proteins and p-NF-κBp65, NF-κBp65, BACE1, APP and Aβ proteins or genes were significantly increased in the infected HT22. In addition, CD80, pro-inflammatory factors, notch, hes1 proteins and genes were enhanced in the infected BV2. Interestingly, not only the APP and pro-apoptotic proteins in HT22, but also the apoptosis rate of HT22 increased after the infected BV2 were co-cultured with the HT22 in a transwell device.

CONCLUSIONS

Neuron apoptosis, Aβ deposition and neuroinflammatory response involved with microglia polarization are the molecular and cellular mechanisms by which TgCtwh6 causes mouse cognitive behavioral abnormalities.

Association between grip strength and cognitive impairment in older American adults

BACKGROUND AND AIMS

Exponential population aging has led to an increased prevalence of cognitive impairment worldwide. Hand grip strength, which may be associated with physical activity, could be a useful predictor of cognitive impairment. However, few studies have reported the association, if any, between hand grip strength and cognitive function.

METHODS

We used data obtained from the National Health and Nutrition Examination Survey between 2011-2012 and 2013-2014 to investigate the association between hand grip strength and cognitive impairment. Cognitive impairment was assessed using the Consortium to Establish a Registry for Alzheimer's Disease (CERAD), animal fluency (AF), and digit symbol substitution test (DSST) scores. Cutoff values of CERAD < 5, AF < 14, and DSST < 34 were used to define cognitive impairment. In this cross-sectional study, we used odds ratios to determine the potential usefulness of hand grip strength for the prediction of cognitive impairment.

RESULTS

This study included 2,623 participants aged ≥60 years. The DSST results showed that hand grip strength was associated with a low risk of cognitive impairment and that subgroup analysis showed that male sex, 60-69 years of age, and the Non-Hispanic (NH)-White, NH Black, and Asian were associated with a significantly low risk of cognitive impairment. The CERAD test results showed that 70-79 years of age and the NH White were significantly associated with a low risk of cognitive impairment. By following full adjustment, we did not observe statistically significant differences between hand grip strength and cognitive impairment based on the CERAD test. The AF test results showed that >80 years of age, female sex, and the NH White were associated with a significantly low risk of cognitive impairment. The most important finding is that a linear association lies between grip strength and cognitive impairment, as well as a sex-based linear association. Machine learning of the XGBoost model suggests that grip strength is one of the top two most important negative predictor variables.

CONCLUSION

We observed an inverse relationship between hand grip strength and cognitive impairment, which might suggest a shared underlying mechanism that needs to be further investigated using a large-scale prospective clinical trial to validate our findings.