Comorbidity in dementia: an autopsy study

Cerebral perivascular spaces as predictors of dementia risk and accelerated brain atrophy

Cerebral small vessel disease, an important risk factor for dementia, lacks robust, in vivo measurement methods. Perivascular spaces (PVS) on brain MRI are surrogates for small parenchymal blood vessels and their perivascular compartment, and may relate to brain health. We developed a novel, robust algorithm to automatically assess PVS count and size on MRI, and investigated their relationship with dementia risk and brain atrophy. We analyzed 46,478 clinical measurements of cognitive functioning and 20,845 brain MRI scans from 10,004 participants (71.1±9.7 years-old, 56.6% women). Fewer PVS and larger PVS diameter at baseline were associated with higher dementia risk and accelerated brain atrophy. Longitudinal trajectories of PVS markers were significantly different in non-demented individuals who converted to dementia compared with non-converters. In simulated placebo-controlled trials for treatments targeting cognitive decline, screening out participants less likely to develop dementia based on our PVS markers enhanced the power of the trial. These novel radiographic cerebrovascular markers may improve risk-stratification of individuals, potentially reducing cost and increasing throughput of clinical trials to combat dementia.

Relationship between aging-related pulmonary function, cognition, motor function, and activities of daily living in older adults with dementia

BACKGROUND: The aging process is related to cerebrovascular dysfunction and physiological changes, such as reduced pulmonary function. This ultimately induces cognitive impairment or dementia. OBJECTIVE: This study aimed to determine the relationship between aging-related pulmonary function, cognition, motor function, and activities of daily living (ADLs) in older adults with dementia. METHODS: This cross-sectional study included 69 older adults diagnosed with dementia. Aging-related pulmonary function and cognition were measured using a hand-held spirometer and the Korean version of the Mini-Mental State Examination (MMSE-K), respectively. To assess motor function and ADLs, the Berg Balance Scale (BBS), 10-meter walk test (10-MWT), 6-minute walk test (6-MWT), and modified Barthel index (MBI) were used to measure balance, walking speed, physical functional capacity (or walking tolerance), and ADLs, respectively. All data were analyzed using the Pearson’s product correlation coefficient (r). RESULTS: Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) as measures of aging-related pulmonary function correlated only with the 6-MWT (FVC: r = 0.483, p = 0.002; FEV1: r = 0.512, p = 0.001). In cognitive function, MMSE-K was associated with BBS (r = 0.283, p = 0.022) and MBI (r = 0.454, p = 0.000). Additionally, there were significant correlations (r = 0.425–0.671, p = 0.000) between all motor function and ADLs measures in older adults with dementia. CONCLUSIONS: Our findings demonstrated that aging-pulmonary function was related to a lower physical functional capacity, and hence, suggested that the reduced pulmonary function were unable to walk for longer distance in older adults with dementia.

Amyloid Beta Pathology Exacerbates Weight Loss and Brain Cytokine Responses following Low-Dose Lipopolysaccharide in Aged Female Tg2576 Mice

Systemic inflammation has been implicated in the progression of Alzheimer’s disease (AD); however, less is understood about how existing AD pathology contributes to adverse outcomes following acute inflammatory insults. In the present study, our goal was to determine how AD-associated amyloid beta (Aβ) pathology influences the acute neuroinflammatory and behavioral responses to a moderate systemic inflammatory insult. We treated 16–18-month-old female Tg2576 (Tg) mice, which overproduce human Aβ and develop plaques, and age-matched wild-type (WT) littermate mice with an intraperitoneal injection of 0.33 mg/kg lipopolysaccharide (LPS) or saline. Mice were then evaluated over the next 28 h for sickness/depressive-like behaviors (food intake, weight loss, locomotion, and sucrose preference), systemic inflammation (serum amyloid A, SAA), blood-brain barrier (BBB) disruption, astrogliosis (glial fibrillary acidic protein/GFAP), Aβ, and cytokine levels in the brain. We found that LPS caused a larger reduction in body weight in Tg vs. WT mice, but that other behavioral responses to LPS did not differ by genotype. BBB disruption was not apparent in either genotype following LPS. Concentrations of the systemic inflammatory marker, SAA, in the blood and brain were significantly increased with LPS but did not significantly differ by genotype. GFAP was increased in Tg mice vs. WT but was not significantly affected by LPS in either genotype. Finally, LPS-induced increases of eight cytokines (IL-1β, IL-6, IL-12 (p40), IL-10, IL-17A, MIP-1α/CCL3, MIP-1β/CCL4, and RANTES/CCL5) were found to be significantly higher in Tg mice vs. WT. In summary, our data show that Aβ pathology exacerbates the neuroinflammatory response to LPS and identifies cytokines that are selectively regulated by Aβ. The association of worse neuroinflammation with greater weight loss in Tg mice suggests that Aβ pathology could contribute to poor outcomes following a systemic inflammatory insult.

Dementia and autopsy-verified causes of death in racially-diverse older Brazilians

BACKGROUND

While dementia has been associated with specific causes of death, previous studies were relatively small autopsy series or population-based studies lacking autopsy confirmation and were restricted to Non-Latinx Whites. Here, we examine the association of dementia with autopsy-verified causes of death in racially-diverse older Brazilians.

METHODS

As part of the Pathology, Alzheimer´s and Related Dementias Study (PARDoS), a community-based study in Brazil, we included 1941 racially-diverse deceased, 65 years or older at death. We conducted a structured interview with legal informants including the Clinical Dementia Rating (CDR) Scale for dementia proximate to death. Causes of death were assessed after full-body autopsy and macroscopic examination of the brain, thoracic and abdominal/pelvic organs. Up to four causes of death were reported for each decedent. Causes of death were classified as circulatory, infectious, cancer and other. Logistic regression was used to determine associations of dementia with cause of death, controlling for age, sex, race, and education.

RESULTS

Dementia was associated with a higher odds of an infectious cause of death (OR = 1.81, 95%CI:1.45-2.25), and with a lower odds of a circulatory disease as cause of death (OR = 0.69, 95%CI:0.54-0.86) and cancer as cause of death (OR = 0.41, 95%CI:0.24-0.71). Dementia was associated with a higher odds of pneumonia (OR = 1.92, 95%CI:1.53-2.40) and pulmonary embolism (OR = 2.31, 95%CI:1.75-3.05) as causes of death and with a lower odds of acute myocardial infarction (OR = 0.42, 95%CI:0.31-0.56) and arterial disease (OR = 0.76, 95%CI:0.61-0.94) as causes of death.

CONCLUSION

Racially-diverse older Brazilians with dementia had a higher odds of an infectious cause of death and a lower odds of cancer and circulatory disease as causes of death than those without dementia.

Causes of death in a nationwide cohort of community-dwellers with Alzheimer's disease

Background

Alzheimer’s disease (AD) is related to higher mortality but it is not entirely evident which causes of death explain this. The objective of this study was to assess the causes of death in a nationwide cohort of clinically verified AD cases and compare the causes to a matched comparison cohort without AD.

Methods

Cohort of all community-dwellers with clinically verified AD residing in Finland on 31 December 2005 (n = 27,948) and a matched comparison cohort without AD (n = 27,948). Mortality (2006–2012, n = 30,641, 54.8%) and causes of death were obtained from register. Cause of death was ascertained with clinical examination (87.3% of deaths), forensic (8.0%) or medical autopsy (4.7%).

Results

In AD cohort, the most common causes were diseases of the nervous system (49.9%), circulatory system (31.7%) and neoplasms (7.7%), while diseases of circulatory system (53.5%), neoplasms (19.1%) and mental and behavioral disorders (7.3%) contributed for majority of deaths in the comparison cohort. There were no sex-wise differences. People with AD were over 20 times more likely to die due to diseases of the nervous system (OR, 95% CI 22.06, 19.87–24.25) than the comparison cohort, while other causes, e.g., diseases of the circulatory system (0.40, 0.38–0.42), neoplasms (0.35, 0.33–0.38), mental and behavioral disorders (0.27, 0.24–0.30) and external causes of morbidity and mortality (0.72, 0.62–0.81) were less common in the AD cohort.

Conclusions

Although half of the people with AD died due to diseases of the nervous system, cancers and especially cardio/cerebrovascular diseases were still important contributors to the overall mortality among them. This should be acknowledged when planning their terminal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01744-z.

Cause of death in autopsy-confirmed dementia disorders

BACKGROUND AND PURPOSE

Dementia disorders predispose for lethal complications and decrease life expectancy. A more profound knowledge regarding end-stage conditions in dementia could therefore ameliorate treatment and care of these patients.

METHODS

Autopsy reports on 207 deceased individuals with clinically diagnosed neurocognitive disorder/dementia and on 200 neurocognitively healthy individuals of the same age range were studied. Autopsy results, especially cause of death, were compared between the dementia and the control groups.

RESULTS

The two most frequent causes of death in the dementia population were pneumonia (34.3%) and acute myocardial infarction (30.4%). This result differed from that of the control group, in which acute myocardial infarction (42.5%) accounted for most events of deaths, followed by circulatory failure (12.5%). The leading cause of death varied amongst dementia subtypes. Further, in Alzheimer's disease pneumonia was more frequent in severe/advanced cases whilst acute myocardial infarction was more common in milder cases.

CONCLUSIONS

Cause of death differed between the demented and the general population of the same age and between subtypes of dementia. Alzheimer's disease severity was reflected in different final conditions. The findings have relevance for the final stage care and treatment in dementia disorders.

Pneumonia-associated death in patients with dementia: A systematic review and meta-analysis

BACKGROUND

Pneumonia is a serious disease associated with mortality among patients with dementia. However, the reported frequency of pneumonia as a cause of death in patients with dementia varies, the reason for which has not been fully elucidated.

METHODS

We conducted a systematic search in PubMed and the Cochrane Database of Systematic Reviews (inception to December 2016). Two authors independently determined the suitability of studies and potential bias and extracted the data. The primary outcome was frequency of pneumonia-associated death in patients with dementia. Stratified subgroup analysis was conducted among studies grouped according to type of mortality cause (immediate or underlying), information source of mortality cause (autopsy or death certificate), and study setting (clinic, hospital, or nursing home).

RESULTS

We included 7 studies reporting the cause of death among patients with dementia and 12 studies comparing the cause of death among patients with and without dementia. The frequency of pneumonia-associated death among 19 eligible studies was 29.69% (95% confidence interval [CI], 25.86-33.53). Those frequencies differed according to whether the source for information about cause of death was an autopsy confirmation (49.98%; 95% CI, 43.75-56.71) or death certificate (19.65%; 95% CI, 15.48-23.83) and according to whether the type of mortality cause was an indirect cause of death (13.96%; 95% CI, 9.42-18.51) or direct cause of death (44.45%; 95% CI, 29.81-50.10). The risk of pneumonia-associated death in patients with dementia was twice as high as among those without dementia (odds ratio, 2.15; 95% CI, 1.63-2.83; p < 0.001).

CONCLUSION

The various frequencies of pneumonia-associated death in patients with dementia were associated with the information source, type of mortality cause, and study setting. Patients with dementia in the terminal stages urgently require careful clinical management of pneumonia, to maximize patient life expectancy and quality.

Functional and morphological changes of the retinal vessels in Alzheimer's disease and mild cognitive impairment

Imaging and histopathological studies have demonstrated that structural changes of the retina affect subjects with Alzheimer’s disease (AD) or mild cognitive impairment (MCI). The aim of this study was to quantitatively investigate the retinal vessels in these disorders, using dynamic vessel analyzer (DVA) and optical coherence tomography angiography (OCTA) analysis. Twelve subjects with AD, 12 subjects with MCI, and 32 gender- and age-matched controls were prospectively enrolled. Mean ± SD age was 72.9 ± 7.2 years in the AD group, 76.3 ± 6.9 years in the MCI group, and 71.6 ± 5.9 years in the control group (p = 0.104). In the DVA dynamic analysis, the arterial dilation was decreased in the AD group (0.77 ± 2.06%), in the comparison with the control group (3.53 ± 1.25%, p = 0.002). The reaction amplitude was decreased both in AD (0.21 ± 1.80%, <0.0001) and MCI (2.29 ± 1.81%, p = 0.048) subjects, compared with controls (3.86 ± 1.94%). OCTA variables did not differ among groups. In the Pearson correlation analysis, amyloid β level in the cerebrospinal fluid was directly correlated with the arterial dilation (R = 0.441, p = 0.040) and reaction amplitude (R = 0.580, p = 0.005). This study demonstrate that Alzheimer’s and MCI subjects are characterized by a significant impairment of the retinal neurovascular coupling. This impairment is inversely correlated with the level of amyloid β in the cerebrospinal fluid.

Increasing Burden of Complex Multimorbidity Across Gradients of Cognitive Impairment

INTRODUCTION

This study evaluates the burden of multimorbidity (MM) across gradients of cognitive impairment (CI).

METHODS

Using data from the 2010 Health and Retirement Study, we identified individuals with no CI, mild CI, and moderate/severe CI. In addition, we adopted an expansive definition of complex MM by accounting for the occurrence and co-occurrence of chronic conditions, functional limitations, and geriatric syndromes.

RESULTS

In a sample of 18 913 participants (weighted n = 87.5 million), 1.93% and 1.84% presented with mild and moderate/severe CI, respectively. The prevalence of most conditions constituting complex MM increased markedly across the spectrum of CI. Further, the percentage of individuals presenting with 10 or more conditions was 19.9%, 39.3%, and 71.3% among those with no CI, mild CI, and moderate/severe CI, respectively.

DISCUSSION

Greater CI is strongly associated with increased burden of complex MM. Detailed characterization of MM across CI gradients will help identify opportunities for health care improvement.

Utilization of Western medicine and traditional Chinese medicine among patients with Alzheimer's disease in Taiwan: a nationwide population-based study

BACKGROUND AND PURPOSE

Large-scale studies of utilization of medical services among patients with Alzheimer's disease (AD) are lacking. We aimed to investigate the usage of Western medicine and traditional Chinese medicine (TCM) among these patients in Taiwan.

METHODS

We analyzed one million samples from the National Health Insurance Research Database in Taiwan. Patients (n = 1814) newly diagnosed with AD in 2001-2010 were divided into TCM users (n = 528) and non-TCM users (n = 1286).

RESULTS

Compared with non-TCM users, TCM users were younger, had a higher female:male ratio and higher utilization rate of Western medicine. The median interval between diagnosis and the first TCM consultation was 7.92 months. Donepezil and rivastigmine were commonly prescribed medications. Chinese herbal medicine was the most popular treatment among TCM users.

CONCLUSIONS

This study revealed the specific usage patterns of TCM and non-TCM medical services among patients with AD. The information could be used for improving the healthcare of patients with AD.

Factors Associated with Pneumonia-caused Death in Older Adults with Autopsy-confirmed Dementia

Objective A better understanding of risk factors for pneumonia-caused death may help to improve the clinical management of dementia. Methods A retrospective observational study was conducted by reviewing the medical charts and autopsy reports of 204 patients who were admitted to hospital, underwent a post-mortem examination, and who were neuropathologically diagnosed with dementia. The risk factors for pneumonia-caused death were examined both as underlying and immediate causes of death using logistic regression models. Results A high frequency of pneumonia-caused death was observed both in underlying- (37.3%) and immediate- (44.1%) cause of death, but varied according to the subtypes of dementia. The factors related to pneumonia-caused death (underlying) were subtypes of dementia; Alzheimer's disease (odds ratio [OR], 2.891; 95% confidence interval [CI], 1.459-5.730); argyrophilic grain disease (OR, 3.148; 95% CI, 0.937-10.577); and progressive supranuclear palsy (OR, 34.921; 95% CI, 3.826-318.775), dysphagia (OR, 2.045; 95% CI, 1.047-3.994), diabetes mellitus (OR, 3.084; 95% CI, 1.180-8.061) and conversely related with heart failure (OR, 0.149; 95% CI, 0.026-0.861). Factors relating to pneumonia-caused death (immediate) were incidence of pneumonia during hospitalizations (OR, 32.579; 95%CI, 4.308-246.370), gender-male (OR, 2.060; 95% CI, 1.098-3.864), and conversely related with malignant neoplasm (OR, 0.220; 95% CI, 0.058-0.840). Conclusion The different factors relating to the pneumonia-caused death were evaluated depending on whether pneumonia was the underlying- or immediate-cause of death. Strengthening clinical management on dysphagia and diabetes mellitus, and preventing incidence of pneumonia during hospitalization appear to be the important for the terminal stage of hospitalized patients with dementia.

Infection as cause of immobility and occurrence of venous thromboembolism: analysis of 1635 medical cases from the RIETE registry

Several risk assessment models include infection and immobility among the items to be considered for venous thromboembolism (VTE) prevention. However, information on patients with infection leading to immobility and developing VTE are limited, as well as on the role of specific types of infection. Data were collected from the worldwide RIETE registry, including patients with symptomatic objectively confirmed VTE, and followed-up for at least 3 months. The overall population of RIETE at June 2013 (n = 47,390) was considered. Acute infection leading to immobility was reported in 3.9 % of non-surgical patients. Compared with patients immobilized due to dementia, patients with infection had a shorter duration of immobilization prior to VTE (less than 4 weeks in 94.2 vs. 25.9 % of cases; p < 0.001). During the 3-month follow-up, VTE patients with infection versus those with dementia had a lower rate of fatal bleeding (0.5 vs. 1.1 %; p < 0.05) or fatal PE (1.7 vs. 3.5 %; p < 0.01). Patients with respiratory tract infections had more likely PE as initial VTE presentation than other types of infection (62.3 vs. 37.7 %; p < 0.001). Significantly more patients with pneumonia than those with other respiratory infections had received VTE prophylaxis (50.2 vs. 30.6 %; p < 0.001). Following VTE, patients with sepsis showed a significantly higher risk of fatal bleeding. Based on our real-world data, infection seems to contribute to the pathogenesis of VTE by accelerating the effects of immobility. Its role as VTE risk factor probably deserves further attention and specific assessment in order to optimize VTE prophylaxis and treatment.

Cumulative dosages of antipsychotic drugs are associated with increased mortality rate in patients with Alzheimer's dementia

OBJECTIVE

We wished to investigate the effects of cumulative dosages of antipsychotic drug in Alzheimer's dementia, when controlling for known risk factors, including current antipsychotic exposure, on all-cause mortality.

METHOD

We utilized a nationwide, population-based, retrospective cohort study design with mortality as outcome in individual patients diagnosed with Alzheimer's dementia.

RESULTS

We included a total of 45 894 patients and followed them for 3 803 996 person-years in total, presenting 27 894 deaths in the study population. Cumulative antipsychotic exposure increased mortality: more than 0 Daily Defined Dosage (DDDs) but less than 90: HR 2.20, 95% CI (2.14-2.27), P < 0.001; more than or equal to 90 DDDs but less than 365: HR 1.81, 95% CI (1.74-1.89), P < 0.001; more than or equal to 365 DDDs but less than 730: HR 1.38, 95% CI (1.428-1.49), P < 0.001; and more than or equal to 730 DDDs: HR 1.06, 95% CI (0.95-1.18), P = 0.322, when controlling for proxy markers of severity, somatic and mental comorbid disorders.

CONCLUSION

In this nationwide cohort study of 45 894 patients diagnosed with Alzheimer's dementia, we found that cumulative dosages of antipsychotic drugs were associated with increased mortality rates.

Influence of pneumonia complications on the prognosis of patients with autopsy-confirmed Alzheimer's disease, dementia with Lewy bodies, and vascular dementia

BACKGROUND

Pneumonia is a major, complicated disease in patients with dementia. However, the influence of pneumonia on the prognosis of patients with varying types of dementia has not been fully evaluated.

METHODS

We retrospectively analyzed the data from medical and autopsy reports. All study patients had been hospitalized and underwent brain autopsy in a hospital in Toyohashi, Japan, between 2005 and 2014. The patients with subtypes of dementia, specifically Alzheimer's disease (AD), dementia with Lewy bodies (DLB), or vascular dementia (VaD), were neuropathologically diagnosed and examined. Pneumonia incidence, cause of death, and the clinical time-course of dementia were compared among the dementia subtypes. The time to death from dementia onset (survival time) was compared by the Kaplan-Meier method among subtypes of dementia with or without pneumonia. Risk factors for survival time on all study patients were analyzed with the Cox proportional hazard model.

RESULTS

Of the 157 eligible patients, 63 (40.1%) had AD, 42 (26.8%) had DLB, and 52 (33.1%) had VaD. Pneumonia complication was observed with high incidence in each subtype of dementia, especially in DLB (90.5%). The median total duration from dementia onset to death was 8 years in AD and DLB, and 5 years in VaD. The VaD subtype had more male patients than AD or DLB (P = 0.010), and age of death in this group was the youngest among the three groups (P = 0.018). A significant difference was observed in the survival time by the Kaplan-Meier method among the three groups (P < 0.001) and among the groups with pneumonia (P = 0.002). The factors associated with shorter survival time were male gender, pneumonia complications, diabetes mellitus, age of dementia onset ≥ 75 years, and VaD.

CONCLUSIONS

Pneumonia complications shortened the survival time of patients with AD, DLB, and VaD.

Relation of cerebral vessel disease to Alzheimer's disease dementia and cognitive function in elderly people: a cross-sectional study

BACKGROUND

Few data on the pathology of cerebral vessel disease, dementia, and cognition are available. We examined the association of cerebral atherosclerosis and arteriolosclerosis neuropathology with probable and possible Alzheimer's disease dementia and cognitive function.

METHODS

This cross-sectional study included men and women aged 65 years or older who had yearly clinical assessments and had agreed to brain autopsy at the time of death, as part of one of two cohort studies of ageing (The Religious Orders Study and the Rush Memory and Aging Project). Individuals without dementia or with Alzheimer's disease dementia, and with complete neuropathological data, are included in our analyses. We used neuropsychological data proximate to death to create summary measures of global cognition and cognitive domains. Clinical data recorded between 1994 and 2015 were used to determine presence of Alzheimer's disease dementia. Systematic neuropathological assessments documented the severity of cerebral large vessel (atherosclerosis) and small vessel (arteriolosclerosis) disease. By use of regression analyses adjusted for demographics, gross and microscopic infarcts, and Alzheimer's disease pathology, we examined associations of vessel disease severity (mild, moderate, and severe) with odds of probable and possible Alzheimer's disease dementia and cognitive function.

FINDINGS

Study enrolment began in January, 1994, and two cohort studies are ongoing. 1143 individuals were included in our analyses (median age at death 88·8 years; 478 [42%] with Alzheimer's disease dementia). Moderate-to-severe atherosclerosis was present in 445 (39%) individuals, and arteriolosclerosis in 401 (35%) individuals. Each level increase in the severity of atherosclerosis or arteriolosclerosis was associated with significantly higher odds of Alzheimer's disease dementia (odds ratio [OR] for atherosclerosis 1·33, 95% CI 1·11-1·58; OR for arteriolosclerosis 1·20, 1·04-1·40). Atherosclerosis was associated with lower scores for global cognition (estimate -0·10 [SE 0·04], p=0·0096) and four cognitive domains (episodic memory -0·10 [0·04], p=0·017; semantic memory -0·11 [0·05], p=0·018; perceptual speed -0·14 [0·04], p=0·00080; and visuospatial abilities -0·13 [0·04], p=0·0080), but not working memory (-0·05 [0·04], p=0·21). Arteriolosclerosis was associated with lower scores for global cognition (estimate -0·10 [0·03], p=0·0015) and four domains (episodic memory -0·12 [0·04], p=0·00090; semantic memory -0·10 [0·04], p=0·013; working memory -0·07 [0·03], p=0·045; perceptual speed -0·12 [0·04], p=0·0012), and a non-significant association was noted for visuospatial abilities (-0·07 [0·03], p=0·052). Findings were unchanged in analyses controlling for the presence of APOE ε4 allele or vascular risk factors.

INTERPRETATION

Cerebral atherosclerosis and arteriolosclerosis are associated with Alzheimer's disease dementia, and are also associated with low scores in most cognitive domains. Cerebral vessel pathology might be an under-recognised risk factor for Alzheimer's disease dementia.

FUNDING

US National Institutes of Health.

Unified theory of Alzheimer's disease (UTAD): implications for prevention and curative therapy

The aim of this review is to propose a Unified Theory of Alzheimer's disease (UTAD) that integrates all key behavioural, genetic and environmental risk factors in a causal chain of etiological and pathogenetic events. It is based on three concepts that emanate from human's evolutionary history: (1) The grandmother-hypothesis (GMH), which explains human longevity due to an evolutionary advantage in reproduction by trans-generational transfer of acquired knowledge. Consequently it is argued that mental health at old-age must be the default pathway of humans' genetic program and not development of AD. (2) Therefore, mechanism like neuronal rejuvenation (NRJ) and adult hippocampal neurogenesis (AHN) that still function efficiently even at old age provide the required lifelong ability to memorize personal experiences important for survival. Cumulative evidence from a multitude of experimental and epidemiological studies indicate that behavioural and environmental risk factors, which impair productive AHN, result in reduced episodic memory performance and in reduced psychological resilience. This leads to avoidance of novelty, dysregulation of the hypothalamic-pituitary-adrenal (HPA)-axis and cortisol hypersecretion, which drives key pathogenic mechanisms of AD like the accumulation and oligomerization of synaptotoxic amyloid beta, chronic neuroinflammation and neuronal insulin resistance. (3) By applying to AHN the law of the minimum (LOM), which defines the basic requirements of biological growth processes, the UTAD explains why and how different lifestyle deficiencies initiate the AD process by impairing AHN and causing dysregulation of the HPA-axis, and how environmental and genetic risk factors such as toxins or ApoE4, respectively, turn into disease accelerators under these unnatural conditions. Consequently, the UTAD provides a rational strategy for the prevention of mental decline and a system-biological approach for the causal treatment of AD, which might even be curative if the systemic intervention is initiated early enough in the disease process. Hence an individualized system-biological treatment of patients with early AD is proposed as a test for the validity of UTAD and outlined in this review.

The Impact of Admission Diagnosis on Recurrent or Frequent Hospitalizations in 3 Dementia Subtypes: A Hospital-Based Cohort in Taiwan with 4 Years Longitudinal Follow-Ups

Increasing numbers of patients with different types of dementia have resulted in the increasing medical care loads. It is not known whether explanatory factors for recurrent or prolong hospitalization were driven by the subtypes of dementia. We analyzed 203 dementia patients aged >65-year-old with a clinical diagnosis of Alzheimer disease (AD), vascular dementia (VaD), or Parkinsonism-related dementia (PRD). With a 4-year follow-up period, logistic regression analyses were used to identify predictors of dementia diagnosis, cerebrovascular risk factors, chronic systemic diseases, and the etiology for admission for recurrent (>4 times/4 years) or prolonged hospitalization stay (>14 days per hospitalization). There were 48 AD, 96 VaD, and 59 PRD patients that completed the 4-year study. The average length of hospital stay was significant, the shortest in AD and the longest in PRD (P = 0.01), whereas the frequency of hospitalization was not different among 3 dementia subtypes. Although delirium is the most common etiology for admission in the patients, diabetes mellitus (Odds ratio, OR = 2.79, P = 0.02), pneumonia (OR = 11.21, P < 0.001), and fall-related hip fracture (OR = 4.762, P = 0.029) were significantly associated with prolong hospitalization. Patients with coronary artery disease (OR = 9.87, P = 0.02), pneumonia (OR = 84.48, P < 0.001), urinary tract infection (OR = 55.09, P < 0.001), and fall-related fracture (OR = 141.7, P < 0.001) predict recurrent hospitalization. Dementia subtypes did not influence directly on the hospitalization courses. The etiologies for admission carried higher clinical significance, compared with the coexisted systemic diseases.

30-Day Mortality after Cardiovascular Events in Persons with or without Alzheimer's Disease

BACKGROUND AND OBJECTIVES

Persons with Alzheimer's disease (AD) have been suggested to receive suboptimal treatment. We studied the 30-day mortality after ischemic stroke, hemorrhagic stroke, or myocardial infarction in individuals with or without AD.

METHODS

An exposure matched cohort of all Finnish community-dwellers diagnosed with clinically verified AD in 2005-2012 (n = 73,005) and 1-4 matched comparison persons/AD-affected person (n = 215,449). Data on 30-day mortality after ischemic stroke (n = 16,419; deaths: n = 2,748), hemorrhagic stroke (n = 3,570; deaths: n = 1,224), and myocardial infarction (n = 15,304; deaths: n = 3,804) were obtained from the National Hospital Discharge register. The main analyses were restricted to first-ever events.

RESULTS

Persons with AD had slightly higher 30-day mortality after ischemic stroke (adjusted HR 1.36, 95% Confidence interval (CI) 1.24,1.49), hemorrhagic stroke (adjusted HR 1.11, 95% CI 0.98,1.25), or myocardial infarction (adjusted HR, 1.40, 9% CI 1.30,1.51). The associations were not affected by age, gender, or co-morbidities and remained similar when patients with previous ischemic strokes or infarctions were included. The absolute risk increase in 30-day mortality after ischemic or hemorrhagic stroke and myocardial infarction were 4.9% (95% CI 3.3,6.5), 3.3% (95% CI - 1.6,8.2), and 7.5% (95% CI 5.0,10.0), respectively.

CONCLUSIONS

Although the 30-day mortality was somewhat higher in the AD cohort, the absolute differences were small indicating that acute treatment was not notably inferior in AD patients. The slightly higher mortality was not explained by co-morbidities but may reflect the higher mortality of AD persons in general, or treatment practice of patients with severe cognitive impairment.

Lung disease as a determinant of cognitive decline and dementia

Almost 40 million people currently live with dementia but this is estimated to double over the next 20 years; despite this, research identifying modifiable risk factors is scarce. There is increasing evidence that cognitive impairment is more frequent in those with chronic lung disease than those without. Chronic obstructive pulmonary disease affects 210 million people, with cognitive impairment present in 60% of certain populations. Co-morbid cognitive dysfunction also appears to impact on important outcomes such as quality of life, hospitalisation and survival. This review summarises the evidence of an association between cognition, impaired lung function and obstructive lung disease. It goes on to examine the contribution of neuro-imaging to our understanding of the underlying pathophysiology. While the mechanisms of brain pathology and cognitive impairment are likely to be complex and multi-factorial, there is evidence to suggest a key role for occult cerebrovascular damage independent of traditional vascular risk factors, including smoking.

Demographic and medication characteristics of traditional Chinese medicine users among dementia patients in Taiwan: a nationwide database study

ETHNOPHARMACOLOGICAL RELEVANCE

Few studies have reported on the utilization of traditional Chinese medicine (TCM) among dementia patients. The aim of the present study is to analyze factors associated with TCM users in the dementia populations and to investigate the medical conditions related to TCM visits.

MATERIALS AND METHODS

A total of 18,141 dementia patients were screened from the one million sample of the National Health Insurance Research Database. The dementia patients were then divided into TCM users and non-TCM users according to their medical records between 1997 and 2008. Demographic characteristics included gender, age, insured amount, and geographic location and medical conditions including comorbidity diseases, behavioral and psychological symptoms, and anti-dementia medication were also investigated. Their tendency of TCM usage was investigated using a multivariate logistic regression.

RESULTS

In Taiwan, 43.3% dementia patients had sought TCM treatments. The inclination of TCM usage was inversely proportional to age; the younger and early-onset dementia (age less than 55 years) patients constituted the high usage group. Female, living in central Taiwan, and higher insured amount were also associated with higher tendency of TCM use. Multilevel Poisson regression analysis showed that the Adjust odds ratios (OR) of TCM use were 1.80 (95% CI=1.68-1.94), 2.52 (95% CI=2.30-2.76), and 3.41 (95% CI=3.01-3.86) for those with one, two, three or more behavioral and psychological symptoms of dementia (BPSD), respectively compared with dementia sufferers without BPSD. In addition, polypharmacy led to higher utilization of TCM (one type: Adjust OR=1.41, 95% CI=1.28-1.56, two types: Adjust OR=1.97, 95% CI=1.63-2.00; three or more types: Adjust OR=2.95, 95% CI=2.27-2.78). More than 70% TCM visits were treated with Chinese herbal remedies, while others used acupuncture and manipulative therapies. Qi-Ju-Di-Huang-Wan (9.7%) was the most frequently prescribed formula, followed by Jia-Wei-Xiao-Yao-San and Ban-Xia-Bai-Zhu-Tian-Ma-Tang.

CONCLUSION

More than 40% of the dementia patients in Taiwan used TCM. Young-onset dementia, higher number of BPSD, multiple chronic diseases, and polypharmacy were independent predictors for dementia patients seeking TCM medical advice. On the basis of the current findings, additional clinical or epidemiologic study on the prescription patterns of TCM in dementia treatment, or the herb-drug interaction and safety issue can be conducted.

Expression of inducible nitric oxide synthase in keratocystic odontogenic tumour and variants of ameloblastoma - a comparative study

INTRODUCTION

The odontogenic keratocyst (OKC) is a histopathologiocally and behaviourally unique and specific entity. It is the most aggressive and recurrent of all the cysts and shows characteristics resembling both cyst and a tumour. The unique nature of OKC and the recent shift of OKC as a tumour made us evaluate yet another factor, Inducible nitric oxide synthase an (iNos) enzyme which has been implicated in the tumourigenesis of various neoplasms. Aims and Objects: The objective of the study was to analyse and compare the immunohistochemical expression of iNOS in odontogenic keratocysts (OKC's) in variants of ameloblastoma affecting the oral cavity, to determine the neoplastic potential of OKC and to reinforce the classification of OKC as keratocystic odontogenic tumour.

MATERIALS AND METHODS

Thirty two specimens, eight specimens each in OKC, follicular ameloblastoma, plexiform ameloblastoma and unicystic ameloblastoma, taken from the Oral Pathology Department were randomly selected for this study and were evaluated for epithelial expression of iNOS by immunohistochemistry Results: Epithelial immunoreactivity to iNOS was strongly positive in 93.5% of follicular ameloblastomas, 68.7% of plexiform ameloblastomas, 66.9% of odontogenic keratocysts and 66.2% of unicystic ameloblastomas.

CONCLUSION

iNOS may be an important marker involved in the biological behaviour of OKC. Furthermore the presence of increased expression of iNOS in Follicular ameloblastomas followed by Plexiform ameloblastomas, OKCs and Unicystic ameloblastomas is yet another evidence to support that OKC could be considered as a neoplasm.

Emerging concepts in Alzheimer's disease

Alzheimer's disease/senile dementia of the Alzheimer type (AD/SDAT) is the most common neuropathologic substrate of dementia. It is characterized by synapse loss (predominantly within neocortex) as well as deposition of certain distinctive lesions (the result of protein misfolding) throughout the brain. The latter include senile plaques, composed mainly of an amyloid (Aβ) core and a neuritic component; neurofibrillary tangles, composed predominantly of hyperphosphorylated tau; and cerebral amyloid angiopathy, a microangiopathy affecting both cerebral cortical capillaries and arterioles and resulting from Aβ deposition within their walls or (in the case of capillaries) immediately adjacent brain parenchyma. In this article, I discuss the hypothesized role these lesions play in causing cerebral dysfunction, as well as CSF and neuroimaging biomarkers (for dementia) that are especially relevant as immunotherapeutic approaches are being developed to remove Aβ from the brain parenchyma. In addition, I address the role of neuropathology in characterizing the sequelae of new AD/SDAT therapies and helping to validate CSF and neuroimaging biomarkers of disease. Comorbidity of AD/SDAT and various types of cerebrovascular disease is a major theme in dementia research, especially as cognitive impairment develops in the oldest old, who are especially vulnerable to ischemic and hemorrhagic brain lesions.

Comorbidity in dementia: update of an ongoing autopsy study

OBJECTIVES

To examine systemic and central nervous system (CNS) comorbidities of individuals with dementia evaluated during general autopsy.

DESIGN

Retrospective cohort study.

SETTING

A large tertiary academic medical center in Los Angeles, California.

PARTICIPANTS

Individuals with clinically and neuropathologically diagnosed dementia who received complete autopsies (n = 86) and individuals with dementia who received partial (brain only) autopsies (n = 132).

MEASUREMENTS

Information on cause of death and systemic and CNS comorbidities was obtained from autopsy reports and clinical information as available from the medical records. Findings were tabulated with respect to type of dementia, semiquantitative assessment of the severity of cerebral amyloid angiopathy, semiquantitative assessment of the severity of cerebrovascular disease, and evidence of ischemic damage in the brain.

RESULTS

Of 218 subjects with dementia, 175 (80.3%) had Alzheimer's disease alone or in combination with other lesions that might contribute to cognitive impairment, such as cerebrovascular disease and diffuse Lewy body disease (DLBD), 14 (6.4%) had frontotemporal dementia, and seven (3.2%) had isolated DLBD. The most common cause of death in participants with dementia was pneumonia (n = 57, 66.3%), followed by cardiovascular disease (n = 14, 16.3%). Eighteen subjects (20.9%) had lung disease, and 16 (18.6%) had evidence of an old or recent myocardial infarction. Clinically undiagnosed neoplasms included colonic adenocarcinoma, metastatic pulmonary neuroendocrine carcinoma, meningioma, and Schwannoma.

CONCLUSION

Significant comorbidities were discovered at autopsy in individuals with dementia. Understanding the causes of death and associated comorbidities in individuals with various subtypes of dementia is important in the assessment of end-of-life care in these individuals.

Autopsy in Islam and current practice in Arab Muslim countries

Autopsy, or post-mortem examination, is the dissection of a dead body. It is performed for many reasons. Attitudes toward dead bodies vary with religious beliefs and cultural and geographical backgrounds. We have carried out an extensive literature review to determine the Islamic view and current practice of Autopsy, in at least four Arab countries which published their experiences. Several research articles have studied the history of Islamic Autopsy as well as the current situation and legal debates about it. The overwhelming conclusion is that data is lacking. More must be published from Arabic Muslim countries and more research done to correct misconceptions. We also recommend more application of non-invasive Autopsy.

Under-provision of medical care for vascular diseases for people with dementia in primary care: a cross-sectional review

BACKGROUND

Vascular diseases contribute to the causation and progression of clinical dementia.

AIM

To evaluate the quality of medical care for vascular diseases provided to people with dementia, the patient and practice characteristics that influence quality, and to compare care with that provided to those without dementia.

DESIGN AND SETTING

Observational, cross-sectional review of primary care records of people with dementia from 52 general practices from five primary care trusts in the UK, and comparison with publicly available summary data on patients without dementia.

METHOD

A total of 700 patients with ≥1 diagnosed vascular disease or risk factor were identified from dementia registers. Quality of care was measured on 30 indicators from the UK Quality and Outcomes Framework (QOF) for hypertension, coronary heart disease, stroke, diabetes mellitus, atrial fibrillation, heart failure, and smoking. Overall quality of vascular care was calculated for each patient with dementia.

RESULT

Level of care received by people with dementia was significantly lower compared with those without dementia for 22 of 30 (73%) indicators; most notably for measurement processes such as peripheral pulses check and neuropathy testing for diabetes, and cholesterol measures for stroke. Among people with dementia, women, those in care homes, and those with fewer comorbid physical conditions and medications were associated with lower scores for overall quality of vascular care.

CONCLUSION

The quality of medical care provided to people with dementia with regard to vascular diseases is not concordant with quality, as defined by the QOF. Research is needed to improve access to high-quality care.

Chronic diseases, cognition, functional decline, and the Charlson index in elderly people with dementia

OBJECTIVE

To assess the association between chronic degenerative diseases and functional decline, cognition, and mortality prediction.

METHODS

A cross-sectional study was conducted in a geriatrics service in Belo Horizonte, Brazil, involving 424 patients subdivided into two groups: control and dementia. The study analyzed socio-demographic and environmental data, chronic degenerative diseases, the Charlson index, and data on functional and cognitive dementia.

RESULTS

After a univariate analysis, there was a greater frequency of cerebrovascular accident (CVA), urinary incontinence, constipation, and sleep disorder in the dementia group, while the multivariate analysis showed a greater number of environmental factors and sleep disorder. Regarding the Mini Mental State Examination (MMSE), patients with chronic obstructive pulmonary disease (COPD), CVA, and heart failure presented lower scores. There was a greater score in the dementia group with regarding the Charlson index.

CONCLUSION

These comorbidities were associated with the functional decline in elderly people with dementia.

EFNS-ENS Guidelines on the diagnosis and management of disorders associated with dementia

BACKGROUND AND OBJECTIVES

The last version of the EFNS dementia guidelines is from 2007. In 2010, the revised guidelines for Alzheimer's disease (AD) were published. The current guidelines involve the revision of the dementia syndromes outside of AD, notably vascular cognitive impairment, frontotemporal lobar degeneration, dementia with Lewy bodies, corticobasal syndrome, progressive supranuclear palsy, Parkinson's disease dementia, Huntington's disease, prion diseases, normal-pressure hydrocephalus, limbic encephalitis and other toxic and metabolic disorders. The aim is to present a peer-reviewed evidence-based statement for the guidance of practice for clinical neurologists, geriatricians, psychiatrists and other specialist physicians responsible for the care of patients with dementing disorders. It represents a statement of minimum desirable standards for practice guidance.

METHODS

The task force working group reviewed evidence from original research articles, meta-analyses and systematic reviews, published by June 2011. The evidence was classified (I, II, III, IV) and consensus recommendations graded (A, B, or C) according to the EFNS guidance. Where there was a lack of evidence, but clear consensus, good practice points were provided.

RESULTS AND CONCLUSIONS

New recommendations and good practice points are made for clinical diagnosis, blood tests, neuropsychology, neuroimaging, electroencephalography, cerebrospinal fluid (CSF) analysis, genetic testing, disclosure of diagnosis, treatment of behavioural and psychological symptoms in dementia, legal issues, counselling and support for caregivers. All recommendations were revised as compared with the previous EFNS guidelines. The specialist neurologist together with primary care physicians play an important role in the assessment, interpretation and treatment of symptoms, disability and needs of dementia patients.

Population-based 5-year follow-up study in Taiwan of dementia and risk of stroke

Background

This study estimates the risk of stroke within 5 years of newly diagnosed dementia among elderly persons aged 65 and above. We examined the relationship between antipsychotic usage and development of stroke in patients with dementia.

Methods

We conducted a nationwide 5-year population-based study using data retrieved from the Longitudinal Health Insurance Database 2005 (LHID2005) in Taiwan. The study cohort comprised 2243 patients with dementia aged ≥65 years who had at least one inpatient service claim or at least 2 ambulatory care claims, whereas the comparison cohort consisted of 6714 randomly selected subjects (3 for every dementia patient) and were matched with the study group according to sex, age, and index year. We further classified dementia patients into 2 groups based on their history of antipsychotic usage. A total of 1450 patients were classified into the antipsychotic usage group and the remaining 793 patients were classified into the non-antipsychotic usage group. Cox proportional-hazards regressions were performed to compute the 5-year stroke-free survival rates after adjusting for potentially confounding factors.

Results

The dementia patients have a 2-fold greater risk of developing stroke within 5 years of diagnosis compared to non-dementia age- and sex-matched subjects, after adjusting for other risk factors (95% confidence interval (CI) = 2.58–3.08; P<.001). Antipsychotic usage among patients with dementia increases risk of stroke 1.17-fold compared to patients without antipsychotic treatment (95% CI = 1.01–1.40; P<.05).

Conclusions

Dementia may be an independent risk factor for stroke, and the use of antipsychotics may further increase the risk of stroke in dementia patients.

Somatic comorbidities and Alzheimer's disease treatment

Therapeutic strategies in Alzheimer’s disease (AD) must take into account the characteristics of elderly people, who often have somatic comorbidities. Moreover, demented patients are more frequently frailer than older people. They have a higher number of admissions to hospital, a greater prevalence of complications and an increased risk of death. Therapeutic decisions for these patients have to be approached cautiously: aging, a more elevated comorbidity/polytherapy index and frailty contribute to enhance the risk of pharmacological adverse events and drug interactions. The aim of the present study was to focus on risk–benefit profile of pharmacological therapy for AD in relation to somatic comorbidities that often affect these patients. A Medline search (from 2001 to 2012) was performed using as key words dementia, Alzheimer’s disease, drug treatment, somatic comorbidities, side effects/adverse events and elderly. Cholinesterase inhibitors (ChEIs) and memantine represent the main pharmacological strategies effective in reducing the progression of cognitive decline and functional loss in AD. Many conditions very common in the elderly may restrict the use of ChEIs and/or treatment efficacy in AD patients. Memantine has a good efficacy and tolerability profile with better safety in pulmonary, cardiovascular and central nervous system comorbidities compared to ChEIs. Drug interactions with memantine are also more favorable since they concern mostly drugs not commonly used in the elderly. Only a careful evaluation of the associated somatic diseases, taking into account different drugs safety indexes and tolerability, can lead to personalized treatment management, in order to maximize drug efficacy and optimize quality of life.

Cognitive impairment is undetected in medical inpatients: a study of mortality and recognition amongst healthcare professionals

Background

Detecting cognitive impairment in medical inpatients is important due to its association with adverse outcomes. Our aim was to study recognition of cognitive impairment and its association with mortality.

Methods

200 inpatients aged over 60 years were recruited at the Department of General Internal Medicine at University Hospital MAS in Malmö, Sweden. The MMSE (Mini-Mental State Examination) and the CDT (Clock-Drawing Test) were performed and related to recognition rates by patients, staff physicians, nurses and informants. The impact of abnormal cognitive test results on mortality was studied using a multivariable Cox proportional hazards regression.

Results

55 patients (28%) had no cognitive impairment while 68 patients (34%) had 1 abnormal test result (on MMSE or CDT) and 77 patients (39%) had 2 abnormal test results. Recognition by healthcare professionals was 12% in the group with 1 abnormal test and 44-64% in the group with 2 abnormal test results. In our model, cognitive impairment predicted 12-month mortality with a hazard ratio (95% CI) of 2.86 (1.28-6.39) for the group with 1 abnormal cognitive test and 3.39 (1.54-7.45) for the group with 2 abnormal test results.

Conclusions

Cognitive impairment is frequent in medical inpatients and associated with increased mortality. Recognition rates of cognitive impairment need to be improved in hospitals.

Venous thromboembolism in immobilized patients with dementia. Findings from the RIETE registry

BACKGROUND

The natural history of venous thromboembolism (VTE) in patients with dementia has not been thoroughly studied.

METHODS

We used the RIETE Registry data to assess the clinical characteristics, treatment strategies and outcome during the first 3 months after acute VTE in all immobilized patients with dementia.

RESULTS

As of August 2011, 37988 patients had been enrolled, of whom 1316 (3.5%) had dementia. Most patients in both subgroups were initially treated with low-molecular-weight heparin (LMWH). Then, 48% of patients with dementia and 25% of those without dementia received LMWH as long-term therapy. During the first 3 months of anticoagulant therapy, patients with dementia had a higher incidence of fatal pulmonary embolism (PE): 4.0% vs. 1.2% (odds ratio: 3.3; 95% CI: 2.5-4.4) and fatal bleeding: 1.4% vs. 0.5% (odds ratio: 2.9; 95% CI: 1.8-4.6) than those without dementia. In demented patients initially presenting with PE, the incidence of fatal PE during the first week outweighed that of fatal bleeding (42 vs. 4 deaths), but from Day 8, the incidence of fatal PE was similar to the incidence of fatal bleeding. In patients initially presenting with deep vein thrombosis (DVT), there were 4 fatal PE and 8 fatal bleeding events.

CONCLUSIONS

VTE patients with dementia had a high incidence of fatal PE and fatal bleeding. In those initially presenting with PE, the risk of dying of PE far outweighed that of fatal bleeding. In patients presenting with DVT alone, the risk of fatal PE was lower than that of fatal bleeding.

Pathologic lesions in neurodegenerative diseases

This chapter will discuss two of the most widely used approaches to assessing brain structure: neuroimaging and neuropathology. Whereas neuropathologic approaches to studying the central nervous system have been utilized for many decades and have provided insights into morphologic correlates of dementia for over 100 years, accurate structural imaging techniques "blossomed" with the development and refinement of computerized tomographic scanning and magnetic resonance imaging (MRI), beginning in the late 1970s. As Alzheimer disease progresses over time, there is progressive atrophy of the hippocampus and neocortex--this can be quantified and regional accentuation of the atrophy can be evaluated using quantitative MRI scanning. Furthermore, ligands for amyloid proteins have recently been developed--these can be used in positron emission tomography studies to localize amyloid proteins, and (in theory) study the dynamics of their deposition (and clearance) within the brain over time. Neuropathologic studies of the brain, using highly specific antibodies, can demonstrate synapse loss and the deposition of proteins important in AD progression--specifically ABeta and phosphor-tau. Finally, neuropathologic assessment of (autopsy) brain specimens can provide important correlation with sophisticated neuroimaging techniques.

Vascular dementia: Diagnostic criteria and supplementary exams. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology. Part I

Vascular dementia (VaD) is the most prevalent form of secondary dementia and the second most common of all dementias. The present paper aims to define guidelines on the basic principles for treating patients with suspected VaD (and vascular cognitive impairment - no dementia) using an evidence-based, systematized approach. The knowledge used to define these guidelines was retrieved from searches of several databases (Medline, Scielo, Lilacs) containing scientific articles, systematic reviews, meta-analyses, largely published within the last 15 years or earlier when pertinent. Information retrieved and selected for relevance was used to analyze diagnostic criteria and to propose a diagnostic system encompassing diagnostic criteria, anamnesis, as well as supplementary and clinical exams (neuroimaging and laboratory). Wherever possible, instruments were selected that had versions previously adapted and validated for use in Brazil that take into account both schooling and age. This task led to proposed protocols for supplementary exams based on degree of priority, for application in clinical practice and research settings.

Non-psychiatric comorbidity associated with Alzheimer's disease

The burden of medical comorbidity in individuals with Alzheimer's disease is greater than that observed in matched individuals without dementia. This has important implications for all clinicians and healthcare providers who deal with this common condition. The prevalence of vascular risk factors and vascular disease is particularly high. Additionally, associations with a number of other chronic medical conditions have been described, including thyroid disorders, sleep apnoea, osteoporosis and glaucoma. This review gives an overview of evidenced medical (non-psychiatric) comorbidity associated with Alzheimer's disease and briefly explores the underlying mechanisms that may account for these associations.

Alzheimer's disease and co-morbidity: increased prevalence and possible risk factors of excess mortality in a naturalistic 7-year follow-up

BACKGROUND

Subjects with late-onset Alzheimer's disease (AD) have to be sufficiently healthy to live long enough to experience and to be diagnosed with dementia in later life. In contrast, neurodegeneration and cognitive deficits in AD may increase the frequency of co-morbid disorders and their possible influence on mortality. Consequently, we investigated whether the pattern of co-morbidity and its relevance for later death differed between hospitalized AD and age-matched controls subjects.

METHODS

Co-morbid diseases with a prevalence of more than 1% at hospital admission were compared between 634 hospitalized AD and 72,244 control subjects aged above 70 years admitted to the University of Birmingham NHS Trust between 1 January 2000 to 31 December 2007. Risk factors, i.e. co-morbid diseases that were predictors of mortality within the 7-year follow-up, were identified and compared.

RESULTS

Subjects with AD suffer more eating disorders, infections, brain diseases and neck of femur fractures than other hospitalized elderly patients. In contrast, some cardiovascular diseases and diabetes mellitus were less prevalent in AD subjects in comparison with hospitalized controls. Diseases that might have contributed to later mortality in AD were pneumonia, ischemic heart disease and gastroenteritis, but there were no significant differences in their impact on mortality compared to other hospitalized elderly subjects with the same co-morbidities in multivariate logistic regression analyses.

CONCLUSION

Patients with AD have a different pattern of co-morbidity, but die from the same diseases as other hospitalized patients. Infections including pneumonia and diseases that may occur secondary to neurodegeneration and cognitive decline may need special attention in patients with AD who may not be able to identify or report the early symptoms. Preventive measures may be helpful to reduce the high risk and fatal consequences of undetected disease in AD.

Vascular basis for brain degeneration: faltering controls and risk factors for dementia

The integrity of the vascular system is essential for the efficient functioning of the brain. Aging-related structural and functional disturbances in the macro- or microcirculation of the brain make it vulnerable to cognitive dysfunction, leading to brain degeneration and dementing illness. Several faltering controls, including impairment in autoregulation, neurovascular coupling, blood-brain barrier leakage, decreased cerebrospinal fluid, and reduced vascular tone, appear to be responsible for varying degrees of neurodegeneration in old age. There is ample evidence to indicate vascular risk factors are also linked to neurodegenerative processes preceding cognitive decline and dementia. The strongest risk factor for brain degeneration, whether it results from vascular or neurodegenerative mechanisms or both, is age. However, several modifiable risks such as cardiovascular disease, hypertension, dyslipidemia, diabetes, and obesity enhance the rate of cognitive decline and increase the risk of Alzheimer's disease in particular. The ultimate accumulation of brain pathological lesions may be modified by genetic influences, such as the apolipoprotein E ε4 allele and the environment. Lifestyle measures that maintain or improve cardiovascular health, including consumption of healthy diets, moderate use of alcohol, and implementation of regular physical exercise are important factors for brain protection.

Neuropathology in the adult changes in thought study: a review

The neuropathology underlying dementia syndromes in older populations is complex. The contributions of Alzheimer's and Lewy body pathology are well appreciated. Recent studies with brain autopsies have highlighted the high prevalence of vascular disease as an independent, but often co-morbid contributor to dementia. The Adult Changes in Thought Study is a community-based, longitudinal study of brain aging and cognitive decline which has recently confirmed cerebral microinfarcts as a strong correlate of cognitive impairment and dementia. This study examines correlations between clinical characteristics including extensive, longitudinal medication histories, and longitudinal cognitive testing against structural and biochemical features of disease.

Cerebral microinfarcts associated with severe cerebral beta-amyloid angiopathy

Cerebral amyloid angiopathy (CAA) is common in elderly individuals, especially those affected with Alzheimer's disease. Eighteen brains with severe SCAA (SCAA) were compared with 21 brains with mild CAA (MCAA) to investigate whether the presence of SCAA in the brains of demented patients was associated with a higher burden of old microinfarcts than those with MCAA. Immunohistochemistry for CD68 was employed to highlight old microinfarcts in tissue blocks from various brain regions. Old microinfarcts, manually counted by light microscopy, were present in 14 of 18 SCAA brains and in 7 of 21 MCAA brains (P = 0.01, two-tailed Fisher's exact test). The average number of old microinfarcts across geographic regions in each brain ranged from 0 to 1.95 (mean rank 24.94, sum of ranks 449) in the SCAA group, and from 0 to 0.35 (mean rank 15.76, sum of ranks 331) in the MCAA group (P = 0.008, two-tailed Mann-Whitney U-test). Frequent old microinfarcts in demented individuals with severe CAA may contribute a vascular component to the cognitive impairment in these patients.

Comorbidity and clinical features in elderly patients with dementia: differences according to dementia severity

OBJECTIVES

To evaluate comorbidity and clinical features in elderly patients with dementia to determine differences according to dementia severity.

DESIGN

Observational study with medical record review.

SETTING

Eight hospitals in the Barcelona area.

PARTICIPANTS

515 consecutive admissions aged > 64 years with dementia, 89.1% of whom lived in the community.

MEASUREMENTS

We collected data on sociodemographic variables, type of dementia, Barthel Index (BI), Lawton and Brody Index (LI), Mini-Mental State Examination (MMSE), Charlson Index and the total number of drugs chronically prescribed. We stratified the population into two groups according to disease severity with the Global Deterioration Scale (GDS): mild-moderate (GDS 3-5) and severe (GDS 6-7).

RESULTS

There were a total of 515 participants of which 364 females (70%) and 151 males with a mean age of 81 +/- 6 years old. The total number of chronic prescription drugs was 5.6 +/- 2.4. The mean Charlson Index score was 2 +/- 1.2. The 270 (52.5%) patients with a GDS score of 3-5 were compared with the 245 patients with a GDS score of 6-7. In the multivariate analysis, a GDS score of 6-7 was associated with poorer LI, BI, and MMSE scores and greater neuroleptic therapy.

CONCLUSIONS

Important comorbidity conditions are common in elderly individuals with dementia. The patients with more severe dementia had poor functional status and higher frequency of neuroleptic use. Medical comorbidities should be taken into account in the management of patients with dementia.

The impact of declining clinical autopsy: need for revised healthcare policy

In Western countries, autopsy rates for patients deceased in hospitals have dropped to record lows, while the average frequency of major errors in clinical diagnoses has more than doubled during the same time period. Meanwhile, the Institute of Medicine and the U.S. Department of Health and Human Services have called attention to the high frequency of errors affecting patient safety, bringing the issue of public safety to the forefront of public health concerns. Although autopsies represent a vital tool for the acquisition of new medical knowledge and for medical quality assurance, health care professionals, insurers, and politicians apparently have not chosen the right approach to solve the problem of declining autopsy rates. The present article reviews the current status of clinical autopsies and addresses causes and consequences of their neglect and appeal the urgent need to revise the policy for clinical autopsy.

Improving outcomes of elderly patients with community-acquired pneumonia

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in elderly patients. Therefore, efforts to optimize the healthcare process for patients with CAP are warranted. An organized approach to management is likely to improve clinical results. Assessing the severity of CAP is crucial to predicting outcome, deciding the site of care, and selecting appropriate empirical therapy. Unfortunately, current prognostic scoring systems for CAP such as CURB-65 (confusion, uraemia, respiratory rate, low blood pressure and 65 years of age) or the Pneumonia Severity Index have not been validated specifically in older adults, in whom assessment of mortality risk alone might not be adequate for predicting outcomes. Obtaining a microbial diagnosis remains problematic and may be particularly challenging in frail elderly persons, who may have greater difficulties producing sputum. Effective empirical treatment involves selection of a regimen with a spectrum of activity that includes the causative pathogen. Although most cases of CAP are probably caused by a single pathogen, dual and multiple infections are increasingly being reported. Streptococcus pneumoniae remains the overriding aetiological agent, particularly in very elderly people. However, respiratory viruses and 'atypical' organisms such as Chlamydia pneumoniae are being described with increasing frequency in old patients, and aspiration pneumonia should also be taken into consideration, particularly in very elderly subjects and those with dementia. Age >65 years is a well established risk factor for infection with drug-resistant S. pneumoniae. Clinicians should be aware of additional risk factors for acquiring less common pathogens or antibacterial-resistant organisms that may suggest that additions or modifications to the basic empirical regimen are warranted. In addition to administration of antibacterials, appropriate supportive therapy, covering management of severe sepsis and septic shock, respiratory failure, as well as management of any decompensated underlying disease, may be critical to improving outcomes in elderly patients with CAP. Immunization with pneumococcal and influenza vaccines has also been demonstrated to be beneficial in numerous large studies. There is good evidence that implementation of guidelines leads to improvement in clinical outcomes in elderly patients with CAP, including a reduction in mortality. Protocols should address a comprehensive set of elements in the process of care and should periodically be evaluated to measure their effects on clinically relevant outcomes. Assessment of functional clinical outcome variables, in addition to survival, is strongly recommended for this population.

Prevalence of dementia subtypes: a 30-year retrospective survey of neuropathological reports

We investigated the distribution of neuropathologically defined dementia subtypes among individuals with dementia disorder. The neuropathological reports were studied on all patients (n=524; 55.3% females; median age 80, range 39-102 years) with clinically diagnosed dementia disorder who underwent complete autopsy including neuropathological examination within the Department of Pathology at the University Hospital in Lund, Sweden, during the years 1974-2004. The neuropathological diagnosis was Alzheimer's disease (AD) in 42.0% of the cases, vascular dementia (VaD) in 23.7%, dementia of combined Alzheimer and vascular pathology in 21.6%, and frontotemporal dementia in 4.0% of the patients. The remaining 8.8% of the patients had other dementia disorders, including combinations other than combined Alzheimer and vascular pathology. The registered prevalence of dementia subtypes depends on many variables, including referral habits, clinical and neuropathological judgments and diagnostic traditions, all of these variables potentially changing over time. This, however, does not seem to obscure the delineation of the major dementia subgroups. In this material of 30 years from Lund in the south of Sweden, AD by far dominated among dementia subtypes, while cerebrovascular pathology corresponded with the dementia disorder, either entirely or partly, in almost half of the demented patients.

Glial cell dysregulation: a new perspective on Alzheimer disease

Alzheimer disease (AD) is a major cause of dementia. Several mechanisms have been postulated to explain its pathogenesis, beta-amyloid (A beta toxicity, cholinergic dysfunction, Tau hyper-phosphorylation, oxidative damage, synaptic dysfunction and inflammation secondary to senile plaques, among others. Glial cells are the major producers of inflammatory mediators, and cytotoxic activation of glial cells is linked to several neurodegenerative diseases; however, whether inflammation is a consequence or the cause of neurodegeneration is still unclear. I propose that inflammation and cellular stress associated with aging are key events in the development of AD through the induction of glial dysfunction. Dysregulated inflammatory response can elicit glial cell activation by compounds which are normally poorly reactive. Inflammation can also be the major cause of defective handling of A beta and the amyloid precursor protein (APP). Here I review evidence that support the proposal that dysfunctional glia and the resulting neuroinflammation can explain many features of AD. Evidence supports the notion that damage caused by inflammation is not only a primary cause of neurodegeneration but also an inducer for the accumulation of A beta in AD. Dysfunctional glia can result in impaired neuronal function in AD, as well as in many progressive neurodegenerative disorders. We show that microglial cell activation is enhanced under pro-inflammatory conditions, indicating that glial cell responses to A beta related proteins can be critically dependent on the priming of glial cells by pro-inflammatory factors.