Clinical characteristics and presenting symptoms of dementia - a case-control study of older ethnic minority patients in a Dutch urban memory clinic

OBJECTIVES

Despite the suspected higher prevalence of dementia in first generation ethnic minority populations, little is known about their pathway to geriatric diagnostic facilities. This study describes presenting symptoms, demographic and clinical characteristics of a large cohort of patients from ethnic minority populations at their first visit to a geriatric day clinic and compares them with those of native majority (Dutch) patients.

METHOD

Retrospective case control study in an urban geriatric day clinic setting. Participants were 415 minority patients (cases) from 47 different countries and 428 native Dutch control patients. Measurements were demographic characteristics, cognitive screening results, informant questionnaires, neuropsychiatric and depressive symptoms and somatic comorbidity.

RESULTS

Ethnic minority patients presented with a different profile of psychiatric and somatic comorbidity. They were younger, had longer duration of symptoms and possibly presented somewhat later in the course of the dementia than the controls. Minority patients had more neuropsychiatric and depressive symptoms than native Dutch patients. They also had more often somatic comorbidities than controls, especially diabetes mellitus.

CONCLUSIONS

Clinicians in geriatric diagnostic facilities should be aware of the younger age at presentation and the high prevalence of some specific risk factors for dementia in ethnic minority patients.

Improving Appropriate Prescribing For Geriatric Patients Using a Clinical Decision Support System

Purpose: Polypharmacy is a known risk factor for potentially inappropriate prescribing. Recently there is an increasing interest in clinical decision support systems (CDSS) to improve prescribing. The objective of this study was to evaluate the impact of a CDSS, with the START-STOPP criteria as main content in the setting of a geriatric ward. Endpoints were 1) appropriateness of prescribing and 2) acceptance rate of recommendations.

Methods: This prospective study comparing the use of a CDSS with usual care involved patients admitted to geriatric wards in two teaching hospitals in the Netherlands. Patients were included from January to May 2017. The medications of 64 patients in the first six weeks was assessed according to the current standard, whereas the medications of 61 patients in the second six weeks were also assessed by using a CDSS. Medication appropriateness was assessed with the Medication Appropriateness Index (MAI).

Results: The medications of 125 patients (median age 83 years) were reviewed. In both the usual care group and the intervention group MAI scores decreased significantly from admission to discharge (within group analyses, p<0.001). This effect was significantly larger in the intervention group (p<0.05). MAI scores at discharge in the usual care group and the intervention group were respectively 9.95±6.70 and 7.26±5.07. The CDSS generated 193 recommendations, of which 71 concerned START criteria, 45 STOPP criteria, and 77 potential interactions. Overall, 31.6% of the recommendations were accepted.

Conclusion: This study shows that a CDSS to improve prescribing has additional value in the setting of a geriatric ward. Almost one third of the software-generated recommendations were interpreted as clinically relevant and accepted, on average one per patient.

Tolerability of Lithium: A Naturalistic Discontinuation Study in Older Adults (≥60 Years)

Lithium is one of the most effective treatment options in both bipolar disorder and treatment-resistant depression. The use of lithium in older adults declined during the last decades, probably resulting in undertreatment of older adults. To investigate how well lithium is tolerated in old age, we aimed to determine the frequency, reasons and possible predictors of discontinuation due to adverse effects in a cohort of hospitalized adults aged 60 years or older who had started with lithium.

We performed a retrospective cohort study based on chart reviews. Participants were in treatment at Parnassia Group at The Hague, the Netherlands. After inclusion (between January 2010 and December 2016), participants were followed until April 2017, when we performed data extraction and analysis.

In our sample of 135 patients (median age 69 years, median follow-up duration 18 months), 49 (36.3%) participants discontinued lithium. Only a minority (11 (8.1%)) of the participants discontinued solely due to adverse effects. The majority discontinued lithium due to psychiatric (18,5%) reasons, (most commonly mentioned within this subgroup: lack of effectiveness and non-compliance) or a combination of reasons (7.4%). None of the factors we studied (age, gender, Charlson Comorbidity Index (CCI), polypharmacy, renal function and neurological history) were significantly associated with discontinuation due to adverse effects.

The frequency of lithium discontinuation in our cohort was in range with frequencies reported in younger patients. Older age itself should not be a reason to withhold lithium treatment.

Tolerability of lithium: A naturalistic discontinuation study in older inpatients (≥60 years)

OBJECTIVES

Lithium is one of the most effective treatment options in both bipolar disorder and treatment-resistant depression. The use of lithium in older patients declined during the last decades, probably resulting in undertreatment of older patients. To investigate how well lithium is tolerated in old age, we aimed to determine the frequency, reasons, and possible predictors of discontinuation due to adverse effects in a cohort of inpatients ≥60 years who had started with lithium.

METHODS

We performed a retrospective cohort study based on chart reviews. Participants were in treatment at Parnassia Group at The Hague, The Netherlands. After inclusion (between January 2010 and December 2016), participants were followed until April 2017, when we performed data extraction and analysis.

RESULTS

In our sample of 135 patients (median age 69 years, median follow-up duration 18 months), 49 (36.3%) participants discontinued lithium. Only a minority (11 [8.1%]) of the participants discontinued solely due to adverse effects. The majority discontinued lithium due to psychiatric (18, 5%) reasons (most commonly mentioned within this subgroup: lack of effectiveness and noncompliance) or a combination of reasons (7.4%). None of the factors we studied (age, gender, Charlson Comorbidity Index, polypharmacy, renal function, and neurological history) were significantly associated with discontinuation due to adverse effects.

CONCLUSIONS

The frequency of lithium discontinuation in our cohort was in range with frequencies reported in younger patients. Older age itself should not be a reason to withhold lithium treatment.

Dementia detection with a combination of informant-based and performance-based measures in low-educated and illiterate elderly migrants

OBJECTIVE

Detecting dementia in people who are illiterate or have a low level of education is complicated because many cognitive screening tests are not suitable for these persons. Caregiver or informant-based judgment of cognitive status may aid diagnosis. Our goal was to investigate the diagnostic accuracy of the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) in a population of elderly non-Western migrants with a high illiteracy rate. Second, we wanted to investigate the diagnostic accuracy of IQCODE and Rowland Universal Dementia Screening (RUDAS) combined.

METHOD

109 geriatric outpatients and 20 community controls were included. Geriatricians provided a research diagnosis of intact cognition (n = 27), mild cognitive impairment (MCI; n = 33) or dementia (n = 49). Diagnostic accuracy was calculated for the clinical sample (n = 109). ROC curves for prediction of group status for IQCODE, RUDAS and the combination of both were created.

RESULTS

Predictive validity was high for both IQCODE and RUDAS and was highest for the combination (Area Under the Curve .91). Sensitivity, specificity, Youden index, predictive value, and likelihood ratio for IQCODE and RUDAS are reported.

CONCLUSIONS

In this study in non-Western elderly migrants, half of whom were illiterate, the IQCODE proved to be a valid instrument for dementia detection, and adding the RUDAS increased accuracy. Combining performance-based and informant-based data is recommended to enhance diagnostic precision.

One Size Does Not Fit All: Comparative Diagnostic Accuracy of the Rowland Universal Dementia Assessment Scale and the Mini Mental State Examination in a Memory Clinic Population with Very Low Education

Background

Diagnosing dementia in elderly immigrants is often difficult due to language and cultural barriers, low education, and illiteracy. We compared the diagnostic accuracy of the Rowland Universal Dementia Assessment Scale (RUDAS) to that of the Mini Mental State Examination (MMSE).

Methods

A total of 144 patients (42 with intact cognition, 44 with mild cognitive impairment [MCI], and 58 with dementia) were administered both instruments and were diagnosed by specialists blinded for MMSE and RUDAS results.

Results

Areas under the curve for discriminating intact cognition from MCI and dementia were comparable for RUDAS (0.81; 95% confidence interval 0.74–0.88) and MMSE (0.75; 95% confidence interval 0.69–0.85). Education and literacy were not correlated with the RUDAS but had a medium-large correlation with the MMSE (rho = 0.39).

Conclusions

The study provides additional evidence for the usefulness of the RUDAS in a highly illiterate, culturally diverse geriatric outpatient population.