D-CARE: The Dementia Care Study: Design of a Pragmatic Trial of the Effectiveness and Cost Effectiveness of Health System-Based Versus Community-Based Dementia Care Versus Usual Dementia Care

BACKGROUND/OBJECTIVES

Although several approaches have been developed to provide comprehensive care for persons living with dementia (PWD) and their family or friend caregivers, the relative effectiveness and cost effectiveness of community-based dementia care (CBDC) versus health system-based dementia care (CBDC) and the effectiveness of both approaches compared with usual care (UC) are unknown.

DESIGN

Pragmatic randomized three-arm superiority trial. The unit of randomization is the PWD/caregiver dyad.

SETTING

Four clinical trial sites (CTSs) based in academic and clinical health systems.

PARTICIPANTS

A total of 2,150 English- or Spanish-speaking PWD who are not receiving hospice or residing in a nursing home and their caregivers.

INTERVENTIONS

Eighteen months of (1) HSDC provided by a nurse practitioner or physician's assistant dementia care specialist who works within the health system, or (2) CBDC provided by a social worker or nurse care consultant who works at a community-based organization, or (3) UC with as needed referral to the Alzheimer's Association Helpline.

MEASUREMENTS

Primary outcomes: PWD behavioral symptoms and caregiver distress as measured by the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity and Modified Caregiver Strain Index scales.

SECONDARY OUTCOMES

NPI-Q Distress, caregiver unmet needs and confidence, and caregiver depressive symptoms. Tertiary outcomes: PWD long-term nursing home placement rates, caregiver-reported PWD functional status, cognition, goal attainment, "time spent at home," Dementia Burden Scale-Caregiver, a composite measure of clinical benefit, Quality of Life of persons with dementia, Positive Aspects of Caregiving, and cost effectiveness using intervention costs and Medicare claims.

RESULTS

The results will be reported in the spring of 2024.

CONCLUSION

D-CARE will address whether emphasis on clinical support and tighter integration with other medical services has greater benefit than emphasis on social support that is tied more closely to community resources. It will also assess the effectiveness of both interventions compared with UC and will evaluate the cost effectiveness of each intervention.

Effects of aging on action-intentional programming

BACKGROUND

Action-intentional programs control "when" we initiate, inhibit, continue, and stop motor actions. The purpose of this study was to learn if there are changes in the action-intentional system with healthy aging, and if these changes are asymmetrical (right versus left upper limb) or related to impaired interhemispheric communication.

METHODS

We administered tests of action-intention to 41 middle-aged and older adults (61.9 ± 12.3 years).

RESULTS

Regression analyses revealed that older age predicted a decrement in performance for tests of crossed motor response inhibition as well as slower motor initiation with the left hand.

CONCLUSION

Changes in action-intention with aging appear to be related to alterations of interhemispheric communication and/or age-related right hemisphere dysfunction; however, further research is needed to identify the mechanisms for age-related changes in the brain networks that mediate action-intention.

Improving clinical cognitive testing: report of the AAN Behavioral Neurology Section Workgroup

OBJECTIVE

To evaluate the evidence basis of single-domain cognitive tests frequently used by behavioral neurologists in an effort to improve the quality of clinical cognitive assessment.

METHODS

Behavioral Neurology Section members of the American Academy of Neurology were surveyed about how they conduct clinical cognitive testing, with a particular focus on the Neurobehavioral Status Exam (NBSE). In contrast to general screening cognitive tests, an NBSE consists of tests of individual cognitive domains (e.g., memory or language) that provide a more comprehensive diagnostic assessment. Workgroups for each of 5 cognitive domains (attention, executive function, memory, language, and spatial cognition) conducted evidence-based reviews of frequently used tests. Reviews focused on suitability for office-based clinical practice, including test administration time, accessibility of normative data, disease populations studied, and availability in the public domain.

RESULTS

Demographic and clinical practice data were obtained from 200 respondents who reported using a wide range of cognitive tests. Based on survey data and ancillary information, between 5 and 15 tests in each cognitive domain were reviewed. Within each domain, several tests are highlighted as being well-suited for an NBSE.

CONCLUSIONS

We identified frequently used single-domain cognitive tests that are suitable for an NBSE to help make informed choices about clinical cognitive assessment. Some frequently used tests have limited normative data or have not been well-studied in common neurologic disorders. Utilizing standardized cognitive tests, particularly those with normative data based on the individual's age and educational level, can enhance the rigor and utility of clinical cognitive assessment.

Perceptual-motor dysfunction

PURPOSE OF REVIEW

This article highlights the importance of integrated perceptual information (motor planning, sequencing, and representation) and discusses the integration of these cognitive domains by means of feedforward and feedback loops in the successful acquisition and execution of voluntary behaviors. The article also discusses the dysfunction in the perceptual-motor process that can occur with neurologic injury, resulting in apraxias, agnosia, hemineglect, and Balint syndrome.

RECENT FINDINGS

A combination of functional imaging and lesional studies continues to refine our understanding of the role of the posterior parietal region in the integration of perception with motor action. Different disorders provide contrasting views into the nature of perceptual-motor function and its disruption. Novel rehabilitation techniques may provide improved function in the future.

SUMMARY

Studies continue to demonstrate the importance of unimodal and heteromodal association cortices, as well as the extrapyramidal system (especially the basal ganglia) in perceptual-motor functions across a wide range of activities and disease states. The nondominant hemisphere dictates where attention and intention are to be directed in space, and the dominant hemisphere provides information on how to accomplish skilled complex actions. While the role of perceptual-motor dysfunction in developmental disorders has been long considered, the role of perceptual-motor dysfunction in neurodegenerative diseases, from Parkinson disease to corticobasal syndrome to posterior cortical atrophy, is becoming more apparent. A clear need exists for more robust rehabilitation strategies in these neurodegenerative diseases.

Status of neurology medical school education: results of 2005 and 2012 clerkship director survey

OBJECTIVE

To survey all US medical school clerkship directors (CDs) in neurology and to compare results from a similar survey in 2005.

METHODS

A survey was developed by a work group of the American Academy of Neurology Undergraduate Education Subcommittee, and sent to all neurology CDs listed in the American Academy of Neurology database. Comparisons were made to a similar 2005 survey.

RESULTS

Survey response rate was 73%. Neurology was required in 93% of responding schools. Duration of clerkships was 4 weeks in 74% and 3 weeks in 11%. Clerkships were taken in the third year in 56%, third or fourth year in 19%, and fourth year in 12%. Clerkship duration in 2012 was slightly shorter than in 2005 (fewer clerkships of ≥4 weeks, p = 0.125), but more clerkships have moved into the third year (fewer neurology clerkships during the fourth year, p = 0.051). Simulation training in lumbar punctures was available at 44% of schools, but only 2% of students attempted lumbar punctures on patients. CDs averaged 20% protected time, but reported that they needed at least 32%. Secretarial full-time equivalent was 0.50 or less in 71% of clerkships. Eighty-five percent of CDs were "very satisfied" or "somewhat satisfied," but more than half experienced "burnout" and 35% had considered relinquishing their role.

CONCLUSION

Trends in neurology undergraduate education since 2005 include shorter clerkships, migration into the third year, and increasing use of technology. CDs are generally satisfied, but report stressors, including inadequate protected time and departmental support.

Acute lorazepam effects on neurocognitive performance

A double-blind, placebo-controlled, crossover design was employed to determine whether acute lorazepam (2 mg orally) cognitive side effects would emerge in a differential age-dependent fashion in 15 young (mean age=22 years) and 12 older (mean age=64 years) subjects. Acute use of lorazepam is frequently the initial treatment choice for convulsive status epilepticus or repetitive seizure clusters. Cognitive assessment was performed during drug and placebo conditions using a computerized battery of cognitive tests. With the exception of performance on the reasoning composite score, significant drug effects were present on all primary cognitive domain measures. However, the only significant drug-by-age interaction effect was seen for dual-task performance. The relationship between test performance and plasma lorazepam concentrations was generally modest and non-significant, suggesting that individual differences in pharmacokinetics are not a major factor contributing to the emergence of cognitive side effects. Despite robust lorazepam effects on multiple measures of neurocognitive function, differential age effects are largely restricted to dual-task performance. These results indicate that with the exception of dual-task performance, older individuals in the age range of this study do not appear to be at increased risk for the emergence of cognitive side effects following a single 2-mg dose of lorazepam.

Auditory responsive naming versus visual confrontation naming in dementia

Dysnomia is typically assessed during neuropsychological evaluation through visual confrontation naming. Responsive naming to description, however, has been shown to have a more distributed representation in both fMRI and cortical stimulation studies. While naming deficits are common in dementia, the relative sensitivity of visual confrontation versus auditory responsive naming has not been directly investigated. The current study compared visual confrontation naming and auditory responsive naming in a dementia sample of mixed etiologies to examine patterns of performance across these naming tasks. A total of 50 patients with dementia of various etiologies were administered visual confrontation naming and auditory responsive naming tasks using stimuli that were matched in overall word frequency. Patients performed significantly worse on auditory responsive naming than visual confrontation naming. Additionally, patients with mixed Alzheimer's disease/vascular dementia performed more poorly on auditory responsive naming than did patients with probable Alzheimer's disease, although no group differences were seen on the visual confrontation naming task. Auditory responsive naming correlated with a larger number of neuropsychological tests of executive function than did visual confrontation naming. Auditory responsive naming appears to be more sensitive to effects of increased of lesion burden compared to visual confrontation naming. We believe that this reflects more widespread topographical distribution of auditory naming sites within the temporal lobe, but may also reflect the contributions of working memory and cognitive flexibility to performance.

Normal pressure hydrocephalus

Normal Pressure Hydrocephalus first became recognized as a treatable, reversible disorder in the 1960s. The classic triad of magnetic apraxia, urinary incontinence, and dementia remain relevant into the 21(st) century as being the basis for symptomatic diagnosis and predicting potential benefit from ventriculoperitoneal shunting, though they have been greatly augmented by the addition of modern neuroimaging, particularly MRI. Modern criteria recognize a wider range of diagnostic criteria, and new positive and negative prognostic indicators for treatment benefit have been discovered, though the mainstay remains initial drainage of a large volume of cerebrospinal fluid and monitoring for clinical improvement. Even with our advances in understanding both primary and secondary normal pressure hydrocephalus, diagnosis, management, and counseling remain challenging in this disorder.

Spatial-attention and emotional evocation: line bisection performance and visual art emotional evocation

Lesion studies demonstrate that the right temporal-parietal region (RTP) is important for mediating spatial attention. The RTP is also involved in emotional experiences that can be evoked by art. Normal people vary in their ability to allocate spatial attention, thus, people who can better allocate attention might also be more influenced by the emotional messages of the paintings (evocative impact). Seventeen healthy participants bisected an unlabeled 100mm line and their performance on this task was used to create two groups, individuals who were more (mALB) and less accurate (lALB). These participants also judged 10 paintings on five qualities, Evocative Impact, Aesthetics, Novelty, Technique, and Closure by marking a 100mm line from 1 (low degree) to 10 (high degree). An ANOVA indicated differences in accuracy on the line bisection (LB) between the two groups. Additional ANOVAs, using the quality ratings as the dependent measure, revealed that the mALB group scored the Evocative Impact greater than the lALB group. These results suggest that the differences in attentional bias between the two groups, as indicated by their LB performance, might influence their evocative impact or reactions and also be a 'barometer' of other RTP functions, including emotional processing.

Artwork before and after onset of progressive nonfluent aphasia

OBJECTIVE

Compare changes in art quality before and after the onset of progressive nonfluent aphasia (PA).

BACKGROUND

Some patients with left frontotemporal lobar degeneration (FTLD), particularly PA start painting and improve in art despite their disease. There is only 1 case reported of FTLD where the person was an artist before onset.

METHODS

Digital images of 7 paintings were obtained. Three paintings were from 6 years before onset of PA, 1 was from year of onset, and 3 were from 5 years after. Seven college-educated raters without art backgrounds, 5 men and 2 women, used a 1 to 5 point scale to rate 4 qualities of the paintings: representation, esthetics, novelty, and closure. The subjects had not previously viewed these paintings. One art expert also rated the paintings on these 4 qualities.

RESULTS

Quality ratings did not differ for 3 qualities, but novelty decreased over time. The art expert rated all qualities stable over time.

CONCLUSIONS

Artistic ability in this previously trained artist with PA did not improve. Instead, the novelty of her work decreased. FTLD may not improve artistic skills in those who already possess them and there can be a decrease in one quality strongly related to creativity-novelty.

Ipsilesional attentional-approach neglect or crossover effect

Patients with ipsilateral neglect (IN) bisect lines toward contralesional space. It has been posited that IN might be induced by an attempt at compensation, as part of the crossover effect, where patients with an ipsilesional bias when bisecting long lines, cross over and develop a contralesional bias on short lines or as a release of an approach (grasp) behavior that might be attentional or intentional. To test these alternative hypotheses we had a patient with IN from a right medial frontal lesion bisect lines that contained no cue, a left-sided cue, a right-sided cue, and bilateral cues. If this patient had ipsilateral neglect (IN) because of a crossover effect or compensation, right-sided cues should have influenced bisection more than left-sided cues. We, however, found that only left-sided cues induced a significant change (left-sided deviation) providing support for the attentional-approach (grasp) hypothesis. Further support of this contralesional attentional grasp hypothesis comes from the observation that this patient also had ipsilesional extinction to simultaneous stimuli.

Incremental limb hypometria

To find out if patients with right hemisphere strokes (RHD) demonstrate a form of progressive or incremental limb hypometria (ILH), 11 RHD patients and eight matched controls were tested by having them draw a series of horizontal lines while blindfolded. Unlike controls, six RHD patients displayed an incremental decrease in the length of lines they drew, a sign of ILH. ILH might be a common source of disability and hinder rehabilitation efforts.

Lewy body dementia and creativity: Case report

BACKGROUND

We studied a visual artist with Lewy body dementia (LBD) to learn how this disease influenced his paintings during the course of the disease.

METHODS

Study 1 evaluated two paintings of the same subject matter, one that the patient painted before his illness and the other after the onset of this disease. Study 2 evaluated a collection of his paintings from the time before he was ill (1994) until the time he stopped painting when he was suffering with LBD (2002). To learn how the onset and progression of LBD affected his paintings we had judges score the following qualities: aesthetic-beauty, closure completeness, evocative impact, novelty, technique and representational quality.

RESULTS

In Study 1 we found that the representational ratings for the picture he painted when he had LBD was significantly lower than the picture he painted before he developed LBD. In Study 2, we found that all the artistic qualities measures temporally declined except novelty. We also found that the paintings that were judges as having the highest quality representations were significantly more novel than those that had poorer representations. In addition, we conducted a forward stepwise regression analysis using quality measures as predictor of year. This analysis revealed that only representational quality significantly predicted painting year.

CONCLUSIONS

Our results suggest that as LBD progresses, except for novelty there is a gradual degradation of the ability to visually express artistic subject matter. It possible that the preserved ability to paint novel picture is related to relative preservation of frontal lobe function, but the degradation of other artistic qualities might be related to deterioration of the parietal lobes which either impairs the brain's iconic representations or the knowledge needed to portray these representations.