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Lindauer A, McKenzie G, LaFazia D, Mincks K, Mattek N, Teri L. FIDELITY ASSESSMENT IN THE TELEHEALTH TRANSLATIONAL PROCESS. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.3108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Lindauer
- Oregon Health & Science University, Layton Aging and Alzheimer’s Disease Center, Portland, Oregon, United States
| | - G McKenzie
- Associate Professor, OHSU School of Nursing, Portland, OR, USA
| | - D LaFazia
- Northwest Research Group on Aging, Department of Psychosocial and Community Health, School of Nursing, University of Washington, USA
| | - K Mincks
- Research Assistant, OHSU Layton Aging and Alzheimer’s Disease Center, Portland, OR, USA
| | - N Mattek
- OHSU Layton Aging and Alzheimer’s Disease Center, Portland, OR, USA
| | - L Teri
- Northwest Roybal Center and Northwest Research Group on Aging, University of Washington, Seattle, WA, USA
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Lindauer A, Croff R, Mincks K, Mattek N, Shofner SJ, Bouranis N, Teri L. "It Took the Stress out of Getting Help": The STAR-C-Telemedicine Mixed Methods Pilot. Care Wkly 2018; 2:7-14. [PMID: 30393783 DOI: 10.14283/cw.2018.4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Caring for a family member with Alzheimer's disease and related dementias can be mentally and physically taxing. Support programs are available to mitigate the strain of care, but caregivers report access challenges (e.g., distance). STAR-C is an evidence-based, effective, one-on-one caregiver educational intervention. However, family caregivers who do not live near a STAR-C consultant (e.g., rural caregivers) cannot participate in the program. The earth-bound mode presents a critical barrier to widely-available caregiver support. Objectives We assessed the feasibility, preliminary efficacy, and cost of implementing a caregiver support intervention (STAR-C-Telemedicine), using Internet-based videoconferencing. Design Using a mixed-methods approach, we examined feasibility and pre- and post-intervention changes in caregiver burden. Focus groups provided feedback on program acceptability. Setting Participants, in their own homes, connected the university-based study staff using videoconferencing technology. Participants Twenty family caregivers for those with dementia consented to the study. Intervention The STAR-C-TM intervention included 8 weekly sessions in which the universitybased consultant met (via videoconferencing) with caregivers in their homes. The intervention focused on identifying upsetting behaviors and identifying triggers to the behaviors. Measurements We assessed caregiver burden, depression and desire to institutionalize prior to and after the intervention. Results Fourteen caregivers (82% of those who started the intervention) completed all study components. We found statistically significant reductions in caregiver burden. Caregivers liked the videoconferencing option. Almost two-thirds reported, given the choice, that they would prefer it over an in-person offering. STAR-C-TM saved, on average, $1150/per caregiver over the traditional program. Qualitative findings supported the quantitative data. Conclusions Telemedicine-based support for family caregivers is a feasible and cost-effective option. As the prevalence of dementia grows, programs such as STAR-C-TM can fill an important gap in caregiver education and support.
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Affiliation(s)
- A Lindauer
- Oregon Health & Science University, Portland, Oregon Layton Aging and Alzheimer's Disease Center, USA
| | - R Croff
- Oregon Health & Science University, Portland, Oregon Layton Aging and Alzheimer's Disease Center, USA
| | - K Mincks
- Oregon Health & Science University, Portland, Oregon Layton Aging and Alzheimer's Disease Center, USA
| | - N Mattek
- Oregon Health & Science University, Portland, Oregon Layton Aging and Alzheimer's Disease Center, USA
| | - S J Shofner
- Portland State University, Portland, Oregon, USA
| | - N Bouranis
- Oregon Health & Science University-Portland State University School of Public Health
| | - L Teri
- University of Washington, School of Nursing & Northwest Roybal Center; Northwest Research Group on Aging
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Eagen T, McGough E, Logsdon R, McCurry S, Cagley M, Cunningham A, Teri L. PHYSICAL PERFORMANCE AND ADVERSE HEALTH EVENTS IN OLDER ADULTS WITH DEMENTIA. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.1745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- T. Eagen
- Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - E. McGough
- Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - R.G. Logsdon
- Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - S.M. McCurry
- Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - M. Cagley
- Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - A. Cunningham
- Rehabilitation Medicine, University of Washington, Seattle, Washington
| | - L. Teri
- Rehabilitation Medicine, University of Washington, Seattle, Washington
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Larson EB, Kukull WA, Teri L, McCormick W, Pfanschmidt M, van Belle G, Sumi M. University of Washington Alzheimer’s Disease Patient Registry (ADPR): 1987–8. Aging Clin Exp Res 2013. [DOI: 10.1007/bf03323960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McGough EL, Cochrane BB, Pike KC, Logsdon RG, McCurry SM, Teri L. Dimensions of physical frailty and cognitive function in older adults with amnestic mild cognitive impairment. Ann Phys Rehabil Med 2013; 56:329-41. [PMID: 23602402 DOI: 10.1016/j.rehab.2013.02.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 02/20/2013] [Accepted: 02/26/2013] [Indexed: 01/18/2023]
Abstract
OBJECTIVE The objective of this study was to examine relationships between dimensions of physical frailty and severity of cognitive impairment in older adults with amnestic mild cognitive impairment (aMCI). PATIENTS AND METHODS The prevalence of physical frailty dimensions including slow gait speed, low physical activity, and low grip strength was examined among 201 sedentary older adults with aMCI. Associations between dimensions of physical frailty and severity of cognitive impairment, as measured with the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog) and individual dimensions of cognitive function were examined using multiple linear regression models. RESULTS Greater than 50% of participants met physical frailty criteria on dimensions of slow gait speed, low physical activity and low grip strength. Slower gait speed was associated with elevated severity of cognitive impairment. Both gait speed and physical activity were associated with individual dimensions cognitive function. CONCLUSIONS Dimensions of physical frailty, particularly gait speed, were associated with severity of cognitive impairment, after adjusting for age, sex and age-related factors. Further studies are needed to investigate mechanisms and early intervention strategies that assist older adults with aMCI to maintain function and independence.
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Affiliation(s)
- E L McGough
- Department of Rehabilitation Medicine, University of Washington, 1959, NE Pacific Street, Box 356490, Seattle, WA 98195, USA.
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McGough E, Ciol M, Cochrane B, Engel J, Kelly V, McCurry S, Logsdon R, Teri L. 009 INSTRUMENTAL ACTIVITIES OF DAILY LIVING, EXECUTIVE FUNCTION, AND PHYSICAL PERFORMANCE SPEED IN SEDENTARY OLDER ADULTS WITH MILD COGNITIVE IMPAIRMENT. Parkinsonism Relat Disord 2010. [DOI: 10.1016/s1353-8020(10)70010-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Research evidence strongly suggests that increased physical exercise may not only improve physical function in older adults but may also improve mood and slow the progression of cognitive decline. This paper describes a series of evidence-based interventions grounded in social-learning and gerontological theory that were designed to increase physical activity in persons with dementia and mild cognitive impairment. These programs, part of a collective termed the Seattle Protocols, are systematic, evidence-based approaches that are unique 1) in their focus on the importance of making regular exercise a pleasant activity, and 2) in teaching both cognitively impaired participants and their caregivers behavioral and problem-solving strategies for successfully establishing and maintaining realistic and pleasant exercise goals. While additional research is needed, initial findings from randomized controlled clinical trials are quite promising and suggest that the Seattle Protocols are both feasible and beneficial for community-residing individuals with a range of cognitive abilities and impairments.
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Affiliation(s)
- L Teri
- University of Washington, Seattle, Washington, USA.
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Larson EB, Wang L, Bowen JD, McCormick WC, Teri L, Crane P, Kukull W. Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Scand J Med Sci Sports 2006. [DOI: 10.1111/j.1600-0838.2006.00572.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Li G, Shofer JB, Kukull WA, Peskind ER, Tsuang DW, Breitner JCS, McCormick W, Bowen JD, Teri L, Schellenberg GD, Larson EB. Serum cholesterol and risk of Alzheimer disease: a community-based cohort study. Neurology 2006; 65:1045-50. [PMID: 16217057 DOI: 10.1212/01.wnl.0000178989.87072.11] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To examine the association of serum total cholesterol (TC) and high density lipoprotein (HDL) levels and subsequent incidence of dementia and Alzheimer disease (AD) in a population-based cohort study. METHODS A cohort of cognitively intact persons, aged 65 and older, was randomly selected from Group Health Cooperative (GHC), a large health maintenance organization, and was assessed biennially for dementia. Premorbid levels of TC and HDL were obtained from a computerized clinical laboratory database at GHC. Cox proportional hazards regression was used to calculate hazard ratios (HR, 95% CI) for dementia and AD associated with quartiles of TC and HDL levels. RESULTS Of the 2,356 eligible participants, 2,141 had at least one serum TC measure prior to the initial enrollment. Using the lowest TC quartiles as the reference group, the HR in the highest TC quartiles was not significantly elevated for dementia (1.16, 0.81 to 1.67) or for AD (1.00, 0.61 to 1.62) after adjusting for age, sex, education, baseline cognition, vascular comorbidities, body mass index, and lipid-lowering agent use. Serum HDL showed a similar lack of significant association with risk of dementia or AD. Models that included the presence of one or more APOE-epsilon4 alleles showed a typical association of epsilon4 with AD risk. This association was not materially modified by inclusion of TC level. CONCLUSION The data do not support an association between serum total cholesterol or high density lipoprotein in late life and subsequent risk of dementia or Alzheimer disease (AD). The increased risk of AD with APOE-epsilon4 is probably not mediated by serum total cholesterol levels.
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Affiliation(s)
- G Li
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle, WA, USA.
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Kraybill ML, Larson EB, Tsuang DW, Teri L, McCormick WC, Bowen JD, Kukull WA, Leverenz JB, Cherrier MM. Cognitive differences in dementia patients with autopsy-verified AD, Lewy body pathology, or both. Neurology 2006; 64:2069-73. [PMID: 15985574 PMCID: PMC1513627 DOI: 10.1212/01.wnl.0000165987.89198.65] [Citation(s) in RCA: 193] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the neuropsychological profile of dementia patients from a community-based autopsy sample of dementia, comparing Alzheimer disease (AD), Lewy body pathology (LBP) alone, and LBP with coexistent AD (AD/LBP). METHODS The authors reviewed 135 subjects from a community-based study of dementia for whom autopsy and brain tissue was available. Diagnostic groups were determined according to standard neuropathologic methods and criteria, and the presence of LBs was determined using alpha-synuclein immunostaining. Neuropathologically defined diagnostic groups of AD, AD/LBP, and LBP were examined for differences on neuropsychological test performance at the time of initial study enrollment. RESULTS There were 48 patients with AD alone, 65 with LB and AD pathology (AD/LBP), and 22 with LBP alone (LBP alone). There were no significant differences between groups demographically or on performance of enrollment Mini-Mental State Examination (MMSE) or Dementia Rating Scale (DRS). AD patients performed worse than the LBP patients on memory measures (Fuld Object Memory Evaluation Delayed Recall, Wechsler Memory Scale Logical Memory Immediate and Delayed Recall; p < 0.05) and a naming task (Consortium to Establish a Registry for Alzheimer's Disease Naming; p < 0.05). LBP patients were more impaired than AD patients on executive function (Trail Making Test Part B; p < 0.05) and attention tasks (Wechsler Adult Intelligence Scale-Revised Digit Span; p < 0.05). Decline in MMSE and DRS scores over time were greatest in the patients with AD/LBP. CONCLUSIONS In a community-based sample of older, medically complicated patients with dementia, there are neuropsychological differences between dementia subtypes at the time of diagnosis. In particular, patients with Alzheimer disease (AD) alone and AD/Lewy body pathology (LBP) had more severe memory impairment than patients with LBP. LBP alone was associated with more severe executive dysfunction. Patients with AD/LBP had the most rapid rate of cognitive decline.
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Affiliation(s)
- M L Kraybill
- Mental Illness Research, Education, and Clinical Center, Veterans Administration Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA
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Li G, Higdon R, Kukull WA, Peskind E, Van Valen Moore K, Tsuang D, van Belle G, McCormick W, Bowen JD, Teri L, Schellenberg GD, Larson EB. Statin therapy and risk of dementia in the elderly: a community-based prospective cohort study. Neurology 2005; 63:1624-8. [PMID: 15534246 DOI: 10.1212/01.wnl.0000142963.90204.58] [Citation(s) in RCA: 163] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess the association between statin therapy and risk of Alzheimer disease (AD) in a prospective cohort study with documented statin exposure and incident dementia. METHODS This is a prospective, cohort study of statin use and incident dementia and probable AD. A cohort of 2,356 cognitively intact persons, aged 65 and older, were randomly selected from a health maintenance organization (HMO), and were assessed biennially for dementia. Statin use was identified using the HMO pharmacy database. A proportional hazards model with statin use as a time-dependent covariate was used to assess the statin-dementia/AD association. RESULTS Among 312 participants with incident dementia, 168 had probable AD. The unadjusted hazard ratios (HRs) with statin use were 1.33 (95% CI 0.95 to 1.85) for all-cause dementia and 0.90 (CI 0.54 to 1.51) for probable AD. Adjusted corresponding HRs were 1.19 (CI 0.82 to 1.75) and 0.82 (CI 0.46 to 1.46). A subgroup analysis of participants with at least one APOE-epsilon4 allele who entered the study before age 80 produced an adjusted HR of 0.33 (CI 0.10 to 1.04). CONCLUSION Employing time-dependent proportional hazards modeling, the authors found no significant association between statin use and incident dementia or probable AD. In contrast, when the data were analyzed, inappropriately, as a case-control study, the authors found an OR of 0.55 for probable AD, falsely indicating a protective effect of statins. Study design and analytic methods may explain the discrepancy between the current null findings and earlier findings.
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Affiliation(s)
- G Li
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle, USA.
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Aisen PS, Berg JD, Craft S, Peskind ER, Sano M, Teri L, Mulnard RA, Thomas RG, Thal LJ. Steroid-induced elevation of glucose in Alzheimer's disease: relationship to gender, apolipoprotein E genotype and cognition. Psychoneuroendocrinology 2003; 28:113-20. [PMID: 12445840 DOI: 10.1016/s0306-4530(02)00015-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Glucose and insulin may play an important role in the pathophysiology and symptomatology of Alzheimers disease (AD), and prior studies suggest interactions among glucose, insulin, gender and apolipoprotein E genotype. We analyzed the relationship between steroid-induced glucose elevation and gender, presence of the apolipoprotein E epsilon 4 (APOE-4) allele and cognition using data from a multicenter trial of prednisone therapy in AD. The low-dose prednisone regimen (initial dose: 20 mg/day, maintenance dose: 10 mg/day) caused a moderate increase in random blood glucose (mean post-baseline glucose 115 mg/dl). There was a significant interaction between rise in glucose, gender and presence of the APOE-4 allele. There was no important relationship between glucose and cognitive function at baseline or with prednisone treatment. Meta-analysis including data from three other AD trials showed a small influence of random blood glucose on cognitive scores. These results support a relationship between gender, apolipoprotein E genotype and glucose metabolism, but do not indicate that mild changes in glucose have an important impact on cognitive function.
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Affiliation(s)
- P S Aisen
- Department of Neurology, Georgetown University Medical Center, 1Bles Building, 3800 Reservoir Road NW, Washington, DC 20007, USA.
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Abstract
This study describes two well-characterized groups of Alzheimer's disease (AD) patients with similar levels of cognitive functioning, but with different overall behavioral disturbance levels. We sought to determine the nature of this difference-whether AD patients with higher levels of behavioral disturbance (n = 148) differ from less disturbed AD patients (n = 235) in terms of (a) the range of symptoms exhibited, (b) the frequency of occurrence of these symptoms, or (c) both of these. We defined and operationalized 'diversity of behaviors' and 'frequency' with respect to the item-level responses on the Cohen-Mansfield agitation inventory (CMAI). We found that, in these two samples of AD patients, differences occurred in the frequency of 10 out of 21 behaviors, rather than in a variety of endorsed behaviors. These 10 behaviors, observed at different frequencies in both groups, may be useful for monitoring change in studies of drugs or behavioral interventions for behavioral disturbance in persons with AD.
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Affiliation(s)
- R E Tractenberg
- Alzheimer's Disease Cooperative Study and Department of Neurosciences, University of California, San Diego 92093-0949, USA.
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McCormick WC, Hardy J, Kukull WA, Bowen JD, Teri L, Zitzer S, Larson EB. Healthcare utilization and costs in managed care patients with Alzheimer's disease during the last few years of life. J Am Geriatr Soc 2001; 49:1156-60. [PMID: 11559373 DOI: 10.1046/j.1532-5415.2001.49231.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To learn whether managed care patients with Alzheimer's disease (AD) are more or less costly to care for than patients with other forms of dementia or patients without dementia during the last few years of life. DESIGN Case control study. SETTING A health maintenance organization base population. PARTICIPANTS Three groups of subjects (mean age 85) who were deceased members of a dementia registry obtained from a health maintenance organization base population: 263 subjects with clinically diagnosed probable AD, 133 subjects with other forms of dementia, and 100 cognitively intact controls. MEASUREMENTS Utilization records were examined for the 3 years preceding death. RESULTS In all subcategories and in aggregate, utilization and costs of care were either similar or lower for patients with AD than for the other groups, even after controlling for age, gender, and comorbidity. CONCLUSIONS Persons with AD do not incur higher costs than persons with other types of dementia or age-matched persons without dementia in a mature health maintenance organization during the last few years of life, when utilization is likely to be highest.
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Affiliation(s)
- W C McCormick
- Department of Medicine, University of Washington, Seattle, Washington, USA
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Abstract
This study investigated symptoms of anxiety in two samples of clinic outpatients diagnosed with Alzheimer's disease (AD). Clinician and caregiver reports were obtained using standardized measures to characterize a broad array of anxiety symptoms. Anxiety symptoms were reported for a substantial proportion of subjects, regardless of whether clinician or caregiver ratings were used. Anxious or worried appearance was most common (68% to 71%), followed by fearfulness, tension, restlessness, and fidgeting (37% to 57%). Sleep disturbance and various somatic symptoms were less common (8% to 34%). Although anxiety symptoms were prevalent, only 5% to 6% of subjects met Diagnostic and Statistical Manual of Mental Disorders criteria for the diagnosis of generalized anxiety disorder. In both samples, anxiety symptoms were associated with depression, behavioral disturbances, and increased cognitive impairment. Study findings support a high occurrence of anxiety in patients with dementia, and treatments for anxiety might therefore be helpful in reducing the psychiatric burden of AD.
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Affiliation(s)
- L Ferretti
- Children's Hospital of Buffalo, Washington, USA
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Moceri VM, Kukull WA, Emanual I, van Belle G, Starr JR, Schellenberg GD, McCormick WC, Bowen JD, Teri L, Larson EB. Using census data and birth certificates to reconstruct the early-life socioeconomic environment and the relation to the development of Alzheimer's disease. Epidemiology 2001; 12:383-9. [PMID: 11416775 DOI: 10.1097/00001648-200107000-00007] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The early-life environment and its effect on growth and maturation of children and adolescents are associated with several adult chronic diseases, including Alzheimer's disease. Because it is not feasible to collect information prospectively over the average life span, methods to reconstruct the early-life environment of the aged are necessary to evaluate these associations. In a community-based case-control study conducted in the United States, we collected U.S. census records and birth certificates to reconstruct the early-life socioeconomic environment of each elderly subject. Information was found on 82% of the available Alzheimer's disease cases (239 of 292) and 87% of the available controls (245 of 282). We investigated risk of Alzheimer's disease associated with father's occupation, parental age, household size, sibship size, and birth order. Subjects whose fathers were unskilled manual workers or laborers were at higher risk for Alzheimer's disease (odds ratio = 1.80, 95% confidence interval = 1.19--2.73). The risk of Alzheimer's disease was increased with increasing number of people in the household. We also evaluated whether subjects with the apolipoprotein epsilon 4 allele (APOE epsilon 4), a strong genetic risk factor that is not a necessary cause or a sufficient cause by itself for the development of Alzheimer's disease, were at higher risk than subjects who did not carry this allele. Among subjects with the APOE epsilon 4 allele whose fathers held lower-socioeconomic level occupations, the odds of developing Alzheimer's disease were higher (odds ratio = 2.35, 95% confidence interval = 1.07--5.16) compared with subjects without the allele (odds ratio = 1.40, 95% confidence interval = 0.78--2.52). Subjects carrying the APOE epsilon 4 allele alone have a threefold increased risk of Alzheimer's disease (odds ratio = 3.17, 95% confidence interval = 1.99--5.04). Compared with subjects with neither risk factor, subjects with both the genetic and the environmental risk factors (household size of seven or more and father's occupation being manual) had a relatively high risk of Alzheimer's disease (odds ratio = 14.8, 95% confidence interval = 4.9--46). The data suggest that APOE epsilon 4 may modify the associations between father's occupation, other early-life environmental factors, and development of Alzheimer's disease in late life.
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Affiliation(s)
- V M Moceri
- Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle, WA 98195-7236, USA
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Tractenberg RE, Patterson M, Weiner MF, Teri L, Grundman M, Thomas RG, Thal LJ. Prevalence of symptoms on the CERAD behavior rating scale for dementia in normal elderly subjects and Alzheimer's disease patients. J Neuropsychiatry Clin Neurosci 2001; 12:472-9. [PMID: 11083164 DOI: 10.1176/jnp.12.4.472] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The authors sought to define "abnormal" levels for total scores on the CERAD Behavioral Rating Scale for Dementia (BRSD) and for 37 BRSD items by comparing 242 patients with Alzheimer's disease (AD) and 64 normal elderly control subjects (NEC). BRSD total scores for NEC ranged as high as 52 (out of a maximum 167), and although item prevalence rates were higher for AD patients, not all of these differences were significant. Many symptoms were observed in < or = 10% of AD subjects. Lower Mini-Mental State Examination scores were not consistently associated with lower or higher levels of endorsement across all items. Over 6 and 12 months, endorsement rates were relatively stable for both groups. The authors conclude that assessment of behavior in long-term studies will be needed to quantify "abnormal" levels, and that item-level BRSD information could be important in clinical trials.
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Affiliation(s)
- R E Tractenberg
- Department of Neurosciences, University of California, San Diego 92093-0949, USA.
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Abstract
This article provides an update and review of strategies for assessing and treating behavioral changes in patients with Alzheimer disease. It discusses the impact of behavioral disturbances on patients, presents guidelines for identifying and monitoring behavioral changes, and presents behavioral treatment approaches.
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Affiliation(s)
- L Teri
- Dept. of Psychosocial and Community Health, University of Washington, Seattle 98195-7263, USA
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Teri L, Logsdon RG, Peskind E, Raskind M, Weiner MF, Tractenberg RE, Foster NL, Schneider LS, Sano M, Whitehouse P, Tariot P, Mellow AM, Auchus AP, Grundman M, Thomas RG, Schafer K, Thal LJ. Treatment of agitation in AD: a randomized, placebo-controlled clinical trial. Neurology 2000; 55:1271-8. [PMID: 11087767 DOI: 10.1212/wnl.55.9.1271] [Citation(s) in RCA: 180] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Treatment of agitation is a crucial problem in the care of patients with AD. Although antipsychotic and antidepressant medications and behavior management techniques (BMT) have each been used to treat agitation, clinical trials of these treatments have been characterized by small sample sizes and uncontrolled treatment designs. OBJECTIVE To compare haloperidol, trazodone, and BMT with placebo in the treatment of agitation in AD outpatients. METHODS A total of 149 patients with AD and their caregivers participated in a randomized, placebo-controlled, multicenter trial. Blind assessment was conducted at baseline and after 16 weeks of treatment. The three active treatments were haloperidol, trazodone, and BMT. The Alzheimer's Disease Cooperative Study Clinical Global Impression of Change was the primary outcome measure. Secondary outcomes included patient agitation, cognition, and function, and caregiver burden. RESULTS Thirty-four percent of subjects improved relative to baseline. No significant differences on outcome were obtained between haloperidol (mean dose, 1.8 mg/d), trazodone (mean dose, 200 mg/d), BMT, or placebo. Significantly fewer adverse events of bradykinesia and parkinsonian gait were evident in the BMT arm. No other significant difference in adverse events was seen. Symptoms did not respond differentially to the different treatments. CONCLUSIONS Comparable modest reductions in agitation occurred in patients receiving haloperidol, trazodone, BMT, and placebo. More effective pharmacologic, nonpharmacologic, and combination treatments are needed.
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Affiliation(s)
- L Teri
- University of Washington, Department of Psychosocial and Community Health, Seattle 98195-7263, USA.
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20
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Abstract
In the course of a four-month study of interventions for behavioral disturbances in Alzheimer's disease (AD) patients, the following assessment instruments were examined for validity: the clinical global impression of change (CGIC), Cohen-Mansfield agitation inventory (CMAI); CERAD behavioral rating scale for dementia (BRSD), revised memory and behavioral problems checklist (RMBPC) and the agitated behavior in dementia scale (ABID). The four specific behavioral/agitation scales had excellent cross-sectional and longitudinal correlations with each other, suggesting high validity, but changes as indicated by CGIC scores did not correlate well with change scores on the other instruments. We conclude that specific behavioral instruments are preferable to the more general CGIC for detecting and quantifying behavioral disturbances in AD patients.
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Affiliation(s)
- M F Weiner
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX 75235-9070, USA
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21
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Tsuang D, Larson EB, Bowen J, McCormick W, Teri L, Nochlin D, Leverenz JB, Peskind ER, Lim A, Raskind MA, Thompson ML, Mirra SS, Gearing M, Schellenberg GD, Kukull W. The utility of apolipoprotein E genotyping in the diagnosis of Alzheimer disease in a community-based case series. Arch Neurol 1999; 56:1489-95. [PMID: 10593304 DOI: 10.1001/archneur.56.12.1489] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT A recent collaborative study found that apolipoprotein E (APOE) genotype, in conjunction with the clinical diagnosis of Alzheimer disease (AD), was useful in improving diagnostic specificity (correctly not diagnosing AD) relative to the clinical diagnosis alone. Since these samples are particularly enriched with patients with AD and the APOE epsilon4 allele, results may not be generalizable to patients seen in the general medical community. OBJECTIVE To evaluate the diagnostic utility of the APOE genotype in diagnosing AD in a community-based case series from the largest health maintenance organization in an urban area. DESIGN We examined the effect of including APOE genotype on the diagnosis of AD in a community-based case series of patients presenting with memory complaints. PATIENTS Clinical and neuropathologic diagnoses and APOE genotype were obtained from 132 patients who underwent evaluation for dementia and subsequent autopsy. MAIN OUTCOME MEASURES Sensitivity, specificity, and positive and negative predictive values given various combinations of clinical diagnoses and the presence of an APOE epsilon4 allele. RESULTS Of the 132 patients, 94 had neuropathologically confirmed AD, yielding a prevalence of 71%. The clinical diagnosis alone yielded a sensitivity of 84%, an estimated specificity of 50%, and positive and negative predictive values of 81% and 56%, respectively. The presence of an epsilon4 allele alone was associated with an estimated sensitivity of 59%, specificity of 71%, and positive and negative predictive values of 83% and 41%, respectively. Using the presence of clinical AD and an epsilon4 allele decreased the sensitivity to 49% and increased the specificity to 84%. The positive and negative predictive values were 88% and 40%, respectively. Alternatively, the clinical diagnosis of AD or the presence of an epsilon4 allele in individuals not meeting clinical criteria for AD increases the estimated sensitivity to 94% but decreases the specificity to 37%. The positive and negative predictive values were 79% and 70%, respectively. The changes in the sensitivity and specificity for the combined tests relative to clinical diagnosis alone offset each other. For lower prevalence communities, the positive predictive value will be much lower than those observed herein. CONCLUSIONS Our findings do not support the use of APOE genotyping alone in the diagnosis of AD in the general medical community. Although the presence of an epsilon4 allele in older persons with clinical AD increased the probability of having AD and the absence of an epsilon4 allele in this group decreased the probability of having AD, the association is not strong enough in the differential diagnosis of non-Alzheimer dementia and AD.
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Affiliation(s)
- D Tsuang
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA.
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22
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Logsdon RG, Teri L, Weiner MF, Gibbons LE, Raskind M, Peskind E, Grundman M, Koss E, Thomas RG, Thal LJ. Assessment of agitation in Alzheimer's disease: the agitated behavior in dementia scale. Alzheimer's Disease Cooperative Study. J Am Geriatr Soc 1999; 47:1354-8. [PMID: 10573447 DOI: 10.1111/j.1532-5415.1999.tb07439.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To develop and evaluate the psychometric properties of a new measure of agitation, the Agitated Behavior in Dementia scale (ABID). The ABID consists of 16 items designed specifically to evaluate frequency of and caregiver reaction to common agitated behaviors in community-residing dementia patients. DESIGN The ABID was administered at the baseline assessment of a multi-site controlled treatment study to reduce agitation in Alzheimer's Disease (AD). Reliability was assessed by evaluating internal consistency and test-retest correlations. Validity was assessed by examining correlations with other constructs, including demographics, cognitive status, and overall behavioral disturbance. SETTING Twenty-one sites across the US, comprising the Alzheimer's Disease Cooperative Study, contributed subjects to the investigation. PARTICIPANTS A total of 148 community-residing AD patients, living with a spouse or adult relative who acted as an informant. Mean age was 75 years, and mean Mini-Mental State Exam (MMSE) score was 13. MEASUREMENTS Cognitive status was assessed using the MMSE. Behavioral disturbance was assessed using the Behavior Rating Scale for Dementia of the Consortium to Establish a Registry for Alzheimer's Disease, the Revised Memory and Behavior Problems Checklist, and the Cohen-Mansfield Agitation Inventory. RESULTS Reliability of the ABID was excellent, with internal consistency of 0.70 and test-retest reliability of 0.60 to 0.73. Validity was confirmed by correlations with related measures and lack of correlation with unrelated constructs. CONCLUSIONS The ABID is brief, easy to administer, and provides objectively anchored observations of problems. It is a promising measure for studies of community-residing AD patients.
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Affiliation(s)
- R G Logsdon
- University of Washington, Seattle 98195-7263, USA
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23
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McCurry SM, Edland SD, Teri L, Kukull WA, Bowen JD, McCormick WC, Larson EB. The cognitive abilities screening instrument (CASI): data from a cohort of 2524 cognitively intact elderly. Int J Geriatr Psychiatry 1999; 14:882-8. [PMID: 10521888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
OBJECTIVES To describe the effects of age and education for the Cognitive Abilities Screening Instrument (CASI), a 25-item test of cognitive function. DESIGN Cross-sectional descriptive study of the initial enrollment in a community-based prospective cohort study. PARTICIPANTS A total of 2524 cognitively intact older adults over age 65 who were members of a major health maintenance organization, and who consented to participate in a longitudinal study. MEASUREMENTS Summary scores for the CASI are given in the form of mean, median and percentile distributions specific for age and educational level. RESULTS Based upon maximum likelihood analyses, age and education were significant (p<0.0001) predictors of total CASI score. Increased age and lower education were associated with a lower CASI score, as well as an increased spread in score distribution. Gender was also significantly related (p<0.01) to total CASI, with women having a slightly higher distribution of scores. Mean total scores ranged from CASI=82.2 (SD=9.0) in subjects aged 90-95 who had less than a high school degree to CASI=94.8 (SD=3. 8) in subjects aged 65-69 with at least a high school education. CONCLUSIONS Like most cognitive screening instruments, performance on the CASI in non-demented persons is influenced by age and education. The reference values for 5-year age categories described in this article should be useful for clinicians and research investigators when using the CASI as a measure of cognitive function.
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Affiliation(s)
- S M McCurry
- Department of Psychosocial Health, University of Washington, Seattle, USA.
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24
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McCurry SM, Logsdon RG, Teri L, Gibbons LE, Kukull WA, Bowen JD, McCormick WC, Larson EB. Characteristics of sleep disturbance in community-dwelling Alzheimer's disease patients. J Geriatr Psychiatry Neurol 1999; 12:53-9. [PMID: 10483925 DOI: 10.1177/089198879901200203] [Citation(s) in RCA: 172] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study examined the frequency, predictors, and impact of sleep problems in a population-based sample of 205 Alzheimer's disease (AD) patients. Sleeping more than usual and early morning awakenings were the most common sleep problems reported but were the least disturbing behaviors for caregivers. Night-time awakenings were less common but were most disturbing to caregivers. Using logistic regression analyses, the factors most strongly associated with night awakenings among patients were male gender, greater memory problems, and decreased functional status. Patient depression increased the risk for caregivers to rate patient sleep problems as more disturbing overall. Cluster analyses revealed three characteristic groups of patients who awakened caregivers: one group was inactive during the day but had few other behavior problems; one group had increased levels of fearfulness, fidgeting, and occasional sadness; and the third group had multiple behavior problems, including frequent episodes of sadness, fearfulness, inactivity, fidgeting, and hallucinations. These findings indicate that the nature of sleep problems in AD is multifaceted; future research on the occurrence and treatment of sleep disturbance in dementia patients should consider the patterns of individual differences that may influence its development.
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Affiliation(s)
- S M McCurry
- Department of Psychosocial and Community Health, University of Washington, Seattle 98195-7263, USA
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25
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Abstract
OBJECTIVE To determine the criterion validity and responsiveness to change over time of the Minimum Data Set (MDS). DESIGN Cross sectional analysis comparing prospectively collected research data with MDS data reported from nursing homes on identical subjects. Longitudinal follow-up of subjects allowed for calculation of responsiveness to change over time. PARTICIPANTS Subjects (n = 140) participating in epidemiological research on the natural history of Alzheimer's disease in the University of Washington Group Health Cooperative Alzheimer's Disease Patient Registry (ADPR) who entered nursing homes in Washington State from January 1990 through March 1996. MAIN OUTCOME MEASUREMENTS Spearman's correlation coefficients to compare MDS cognitive performance scale scores with Mini-Mental State Examinations (MMSE), MDS behavior domain scores with ADPR Physician Behavior checklist scores, and MDS activities of daily living (ADL) functioning scores with Dementia Rating Scale scores for ADLs. Partial correlations were used to control for the number of days between MDS and ADPR assessments, age, and function in the other two MDS ratings of ADL, cognition, or behavior. We determined responsiveness by using the mean change in an effect size (ES) calculation for each domain of interest. RESULTS MDS measures in all three domains were correlated modestly to the analogous ADPR research instruments, with correlation coefficients 0.45 for cognition, 0.50 for behavior, and 0.59 for ADL functioning. Controlling for age, time between ADPR and MDS assessments, and the MDS ratings of the other two MDS domains did not improve the correlations significantly. In a subgroup of 60 subjects followed for an average of 636 days, the Cognitive performance scale of the MDS had a slightly larger effect size (ES = 0.60) than the Folstein Mini-Mental Status Exam (ES = 0.39) used by the ADPR. However, the Dementia Rating Scale (ES = 0.77) used by the ADPR researchers reflected more change over time than the ADL domain of the MDS (ES = 0.02). The MDS behavior domain (ES = 0.058) was comparable to the research behavior checklist (ES = 0.065). CONCLUSIONS These data demonstrate reasonable criterion validity of the MDS and the MMSE, ADL, and behavior rating scales and suggest that the MDS data is of adequate validity for research purposes in these areas. The MDS was less able to capture dementia-related change in ADLs in this population of patients with dementia even though the same nursing home staff completing the MDS often supplied the information for completing the research scales. As a result, the MDS may be limited as an outcome assessment instrument.
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Affiliation(s)
- M Snowden
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle 98104, USA
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26
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Teri L, Ferretti LE, Gibbons LE, Logsdon RG, McCurry SM, Kukull WA, McCormick WC, Bowen JD, Larson EB. Anxiety of Alzheimer's disease: prevalence, and comorbidity. J Gerontol A Biol Sci Med Sci 1999; 54:M348-52. [PMID: 10462166 DOI: 10.1093/gerona/54.7.m348] [Citation(s) in RCA: 133] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anxiety may be associated with psychiatric morbidity, disability, increased health care utilization, and mortality in Alzheimer's disease (AD) patients as it is in the general adult population. However, the phenomenology of anxiety symptoms in AD and its relationship to dementia progression, comorbid depression, and the presence of other problematic behaviors have not yet been examined. METHOD Data on anxiety symptoms and their coexistence with other factors were obtained in 523 community-dwelling AD patients through interviews with their caregivers and direct physical examination. The prevalence of anxiety symptoms and their association to patient depression, other behavioral problems, gender, and age was investigated. RESULTS Anxiety symptoms were common, occurring in 70% of subjects. Anxiety symptoms were significantly correlated with ADL impairment and other behavioral disturbances, including wandering, sexual misconduct, hallucinations, verbal threats, and physical abuse. Comorbidity of anxiety-depression was also prevalent: 54% of the sample had both anxiety and depression symptoms. ADL impairment and problem behaviors were significantly associated with comorbidity; however, the latter association was explained entirely by the presence of anxiety. CONCLUSION Anxiety symptoms were common and significantly related to ADL and additional neuropsychiatric problems in this sample. These results indicate the need for additional research into the phenomenology of anxiety and comorbid anxiety-depression in AD and for the development and investigation of effective assessment and treatment of anxiety in AD clinical practice.
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Affiliation(s)
- L Teri
- Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle 98195-7563, USA.
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27
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Lim A, Tsuang D, Kukull W, Nochlin D, Leverenz J, McCormick W, Bowen J, Teri L, Thompson J, Peskind ER, Raskind M, Larson EB. Clinico-neuropathological correlation of Alzheimer's disease in a community-based case series. J Am Geriatr Soc 1999; 47:564-9. [PMID: 10323650 DOI: 10.1111/j.1532-5415.1999.tb02571.x] [Citation(s) in RCA: 234] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Most clinico-neuropathological correlative studies of Alzheimer's Disease (AD) are based on research cohorts that are not necessarily generalizable to patients seen in the general medical community. In this study, we examine the accuracy of the criteria used in diagnosing AD in a community-based case series of patients with memory complaints. DESIGN AND PARTICIPANTS Clinical and neuropathological diagnoses were obtained from 134 patients evaluated for dementia who subsequently underwent autopsy. SETTING Subjects who exhibited new symptoms of dementia and were enrolled in the University of Washington/Group Health Cooperative Alzheimer's Disease Patient Registry were eligible for this study. MEASUREMENTS Clinico-pathological correlation was performed using NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association) and CERAD (Consortium to Establish a Registry for Alzheimer's Disease) criteria. RESULTS Ninety-five of the 134 cases studied met CERAD neuropathological criteria for AD. The sensitivity of NINCDS-ADRDA "probable AD" was 83% (diagnosing AD correctly) and overall clinical diagnostic accuracy was 75%. However, there was a high rate of additional neuropathological findings. Only 34 of the 94 cases had pure AD on neuropathology, whereas the remainder frequently had coexisting vascular or Parkinson's disease lesions. CONCLUSIONS This study of a large series of community-based incident dementia cases provides a way of judging the adequacy of currently available clinical diagnostic criteria. It also shows that co-existing neuropathological findings are common in community-based AD.
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Affiliation(s)
- A Lim
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington 98108, USA
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28
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Abstract
OBJECTIVE In order to determine whether there are racial differences in Alzheimer's Disease (AD) symptom severity and vascular comorbidities, we compared African-American (black) and Caucasian (white) patients with AD from similar socioeconomic backgrounds at the time the disease was first recognized. DESIGN Cross-sectional observational study from a population-based dementia registry. PARTICIPANTS Patients were enrolled from an HMO base population of 23,000 persons more than age 60 in Seattle, Washington. This study examines 453 subjects with probable AD (38 blacks (mean age 76.5, SD 6.4), and 415 whites (mean age 79.7, SD 6.7)). MEASUREMENTS Measured were patient demographics, age at onset of AD, AD symptom duration, Mini-Mental State Exam (MMSE) score, Blessed Dementia Rating Scale, presence of psychiatric symptoms, and vascular comorbidities. RESULTS Blacks had significantly lower mean cognitive scores (MMSE = 17.2, SD 5.6) compared with whites (MMSE = 20.2, SD 5.2, unpaired t test P < .01). The significant racial difference in MMSE scores persisted after controlling for education, duration of AD symptoms, age, and ADL impairment. Blacks and whites did not differ significantly regarding gender distribution, education level, income, or percent with early age of onset of AD. No statistically significant race-related differences were found in impairments in activities of daily living or symptoms of paranoia, hallucinations, or agitation. Blacks had significantly higher rates of hypertension (56%) compared with whites (34%) (Fisher's exact test, P = .013), but the rates of stroke and ischemic heart disease were similar. CONCLUSIONS Despite uniform detection methods and controlling for reported duration of dementia symptoms, measured cognitive impairment is significantly more severe when AD is recognized in blacks compared with whites. The significantly higher prevalence of hypertension among black AD cases was not associated with excess cerebrovascular disease comorbidity. This study highlights a need for normative measurements of cognitive function in minority AD groups in order to distinguish differential cognitive symptom severity from possible measurement bias.
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Affiliation(s)
- M F Shadlen
- Department of Medicine, Alzheimer's Disease Research Center, University of Washington, Seattle, USA
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Teri L. Training families to provide care: effects on people with dementia. Int J Geriatr Psychiatry 1999; 14:110-6; discussion 116-9. [PMID: 10885862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
This paper addresses four questions concerning family training in dementia care: (1) What do we know about what works? (2) How do we know it? (3) What do we now need to know? (4) How should we go about trying to find this out? In addition, it provides some introductory information on the nature of family caregivers in dementia and the phenomenology of caregiver burden and behavioral problems in dementia, often the focus of family training. Training families to provide care to dementia patients has a long clinical history. In recent years, the amount and popularity of this kind of information has grown exponentially, as is evident in the proliferation of books, training materials and informational handouts. Even video and world wide web technology is now used to educate caregivers. Over a decade ago, reports showed that caregivers were able to learn specific behavioral techniques and successfully reduce problematic behaviors. More recently, controlled trials have suggested the effectiveness of caregiver training programs in reducing behavioral problems or delaying institutionalization in patients with dementia. There is much still unknown concerning family training in dementia care. Additional controlled clinical trials are needed, as are additional studies to understand the broader factors known to influence effective care, such as patient and caregiver physical health or family and social supports.
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Affiliation(s)
- L Teri
- Department of Psychosocial and Community Health, University of Washington School of Nursing, Seattle, USA.
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30
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Weiner MF, Koss E, Patterson M, Jin S, Teri L, Thomas R, Thal LJ, Whitehouse P. A comparison of the Cohen-Mansfield agitation inventory with the CERAD behavioral rating scale for dementia in community-dwelling persons with Alzheimer's disease. J Psychiatr Res 1998; 32:347-51. [PMID: 9844950 DOI: 10.1016/s0022-3956(98)00027-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In a group of 242 community-dwelling patients with Alzheimer's disease (AD), a longitudinal comparison was made of two caregiver-administered instruments for assessment of behavioral disturbance; the Cohen-Mansfield Agitation Inventory (CMAI) and the CERAD Behavioral Rating Scale for Dementia (BRSD). We examined records of the 206 patients with baseline and 12-month follow-up data for the CMAI and the BRSD who also had tests of cognitive (Mini-mental State; MMSE) and global function (Clinical Dementia Rating; CDR and Functional Assessment Staging; FAST). Among 114 AD subjects, the correlation between total CMAI at baseline and 1 month readministration was 0.83 (p < 0.0001). In the same subjects, stratified into 5 groups by MMSE scores, the correlations between BRSD baseline and 1-month scores ranged from 0.70-0.89 (p < 0.0001). There was high correlation between total scores of both instruments at baseline and 12 months. In addition, all CMAI subscales except Verbally Aggressive correlated significantly with total BRSD score at both time points. At baseline, BRSD subscales for irritability/aggression, behavioral dysregulation and psychotic symptoms and at 12 months, irritability/aggression and behavioral dysregulation correlated with total CMAI scores. Neither scale changed significantly over 1 year, but there was wide individual variation. CMAI and BRSD scores correlated with 1-year change in the FAST, but not with MMSE or CDR (which weighs cognition heavily), suggesting that behavioral disturbance may be more strongly related to ability to manage activities of daily living (executive function) than to other aspects of cognition. The CMAI and BRSD appear to be interchangeable as measures of agitation, with the CMAI possibly more useful for patients who lack language and the BRSD more sensitive to apathy and depression.
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Affiliation(s)
- M F Weiner
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas 75235-9070, USA
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31
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Teri L, McCurry SM, Buchner DM, Logsdon RG, LaCroix AZ, Kukull WA, Barlow WE, Larson EB. Exercise and activity level in Alzheimer's disease: a potential treatment focus. J Rehabil Res Dev 1998; 35:411-9. [PMID: 10220219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
This article provides information on the baseline health and physical function of 30 individuals with Alzheimer's disease (AD); describes a community-based program designed to increase balance, flexibility, strength, and endurance in these persons by the training of caregivers to facilitate and supervise exercise activity; and documents the adherence of these subjects and their caregivers to this intervention. Subjects were recruited from an ongoing, community-based Alzheimer's Disease Patient Registry, and met NINCDS-ADRDA criteria for probable or possible AD. Caregivers were family members living with the demented individuals in the community. Physical performance was measured using walking speed, functional reach, and standing balance. Health status was measured with the Medical Outcomes Study Short Form, the Sickness Impact Profile, and caregiver reports of subject's restricted activity days, bed disability days, falls, and exercise participation. Baseline data indicated that persons with AD were impaired on measures of physical performance and function, compared to published data on nondemented older adults. During a 12-wk treatment period, caregivers were taught to guide their demented charges in an individualized program of endurance activities (primarily walking), strength training, and balance and flexibility exercises. Adherence data indicated that 100% of the subjects were compliant with some exercise recommendations, and one-third completed all assigned exercises during the training period. Caregivers were able to learn and direct subjects during scheduled exercise activities. These findings indicate that the integration of exercise training into the care of persons with AD is both needed and feasible. Further research is currently underway to determine the efficacy of this approach for reducing additional physical disability in these individuals.
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Affiliation(s)
- L Teri
- Department of Psychosocial and Community Health, University of Washington, Seattle 98195-7263, USA.
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32
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Logsdon RG, Teri L, McCurry SM, Gibbons LE, Kukull WA, Larson EB. Wandering: a significant problem among community-residing individuals with Alzheimer's disease. J Gerontol B Psychol Sci Soc Sci 1998; 53:P294-9. [PMID: 9750566 DOI: 10.1093/geronb/53b.5.p294] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study evaluated the frequency, predictors, and effects of wandering in a population-based sample of 193 individuals with Alzheimer's disease (AD). Although wandering occurred in subjects at all levels of cognitive impairment, analysis of variance indicated that for the group as a whole, greater frequency of wandering was associated with significantly more impairment in cognition, day-to-day functioning, and behavior. Caregiver distress also increased significantly with increased frequency of wandering. Logistic regression modeling identified functional impairment and disruptive behavior problems as the strongest independent predictors of wandering occurring within the past week. Cluster analysis revealed four characteristic groups of wanderers that represented a continuum of wandering frequency, each having a unique pattern of other behavioral disturbances. Based on this analysis, we recommend further evaluation and the development of possible treatment strategies that address the individual differences found among AD patients who wander.
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Craft S, Teri L, Edland SD, Kukull WA, Schellenberg G, McCormick WC, Bowen JD, Larson EB. Accelerated decline in apolipoprotein E-epsilon4 homozygotes with Alzheimer's disease. Neurology 1998; 51:149-53. [PMID: 9674794 DOI: 10.1212/wnl.51.1.149] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The apolipoprotein E-epsilon4 (APOE-epsilon4) allele is a powerful genetic risk factor for the development of Alzheimer's disease (AD). AD patients who are APOE-epsilon4 homozygotes have an earlier age at onset, increased amyloid burden, and decreased acetylcholine levels--findings that suggest differences in disease severity or rate of progression. Studies of genotype differences in rate of decline, however, have produced negative results that may be due to methodologic biases. The current study examined rate of decline in the largest sample of APOE-genotyped AD patients for whom longitudinal cognitive data have been reported. METHODS Newly diagnosed patients with probable AD (n = 201) comprised four genotype groups: epsilon2/3 (n = 14), epsilon3/3 (n = 75), epsilon3/4 (n = 82), and epsilon4/4 (n = 30). The Dementia Rating Scale (DRS) was administered at baseline and then annually for 1 to 6 years (mean, 2.5 years). For each subject, a DRS slope was calculated reflecting annual rate of decline. Rate of decline as measured by DRS slope differed according to genotype, with the effect modified by DRS score (p < 0.014). At the mean DRS score observed in our sample (DRS = 105), the epsilon4/4 group had an increased rate of decline (11.9 points per year) relative to the epsilon2/3 (5.8 points per year; p < 0.003), epsilon3/3 (9.3 points per year; p < 0.076), and epsilon3/4 (9.6 points per year; p < 0.055) groups. At a lower DRS score (DRS = 80), even larger differences were observed among genotypes; the epsilon4/4 group had a increased rate of decline (22.2 points per year) relative to the epsilon2/3 (9.7 points per year; p < 0.0006), epsilon3/4 (15.8 points per year; p < 0.020), and epsilon3/3 (18.2 points per year; p < 0.173) groups. The epsilon2/3 group had a significantly slower rate of decline than all other groups at DRS scores of 80 or 105. CONCLUSIONS APOE-epsilon4 homozygosity is associated with a faster rate of cognitive decline, whereas the epsilon2 allele slows disease progression. These findings suggest that APOE plays a mechanistic role in the progression of AD, and is not simply related to disease onset.
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Affiliation(s)
- S Craft
- Geriatric Research, Education, and Clinical Center, VA Puget Sound Health Care System, and Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle 98018, USA.
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McCurry SM, Logsdon RG, Vitiello MV, Teri L. Successful behavioral treatment for reported sleep problems in elderly caregivers of dementia patients: a controlled study. J Gerontol B Psychol Sci Soc Sci 1998; 53:P122-9. [PMID: 9520929 DOI: 10.1093/geronb/53b.2.p122] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Although sleep problems are common among dementia caregivers, there has been no research thus far describing treatment of such problems using behavioral techniques. In this study, 36 elderly dementia caregivers with disturbed sleep were randomly assigned to either a brief behavioral intervention or a wait list control. The active treatment consisted of standard sleep hygiene, stimulus control, and sleep compression strategies as well as education about community resources, stress management, and techniques to reduce patient disruptive behaviors. Caregivers in active treatment showed significant improvements in sleep at post-treatment and 3-month follow up. No significant differences between groups were observed for caregiver mood, burden, or patient behavior problems, suggesting that sleep improvements were not an artifact of depression treatment. Treatment responders tended to be younger and more compliant with treatment recommendations than non-responders. Results suggest that behavioral techniques may well be a viable alternative to medication for sleep problems in aging caregivers.
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Teri L, Logsdon R, Yesavage J. Measuring behavior, mood, and psychiatric symptoms in Alzheimer disease. Alzheimer Dis Assoc Disord 1998; 11 Suppl 6:50-9. [PMID: 9437448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Behavioral disturbances, psychiatric symptoms, and mood disorders are prevalent, persistent, and debilitating aspects of the clinical course of Alzheimer disease. The authors discuss the phenomenology of these problems, their importance in understanding disease course and planning treatment, and the current state-of-the-art methods for assessment. Issues to consider in assessment of these problems also are discussed.
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Affiliation(s)
- L Teri
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle 98195, USA
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Teri L, Logsdon RG, Whall AL, Weiner MF, Trimmer C, Peskind E, Thal L. Treatment for agitation in dementia patients: A behavior management approach. ACTA ACUST UNITED AC 1998. [DOI: 10.1037/h0087766] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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37
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Teri L. Behavior and caregiver burden: behavioral problems in patients with Alzheimer disease and its association with caregiver distress. Alzheimer Dis Assoc Disord 1997; 11 Suppl 4:S35-8. [PMID: 9339271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Behavioral dysfunction in Alzheimer disease (AD) is a major influence on the morbidity and disability of patients and is central to decisions on patient institutionalization. Behavioral dysfunction ranges from withdrawal, apathy, and depression to hostility, anger, and aggression, with most patients exhibiting some symptoms during the course of the disease. Symptoms of depression are common in AD patients (17-30%) and are associated with broad behavioral dysfunction and increased functional disability. Furthermore, the occurrence of depression in patients correlates strongly with caregiver burden and depression. This report summarizes the relationship between caregiver distress and patient behavioral problems. Administration of the Revised Memory and Behavior Problem Checklist provided information on the frequency of behavioral problems and their association with caregiver distress. In one study of 201 patient-caregiver dyads, depression-related behaviors were confirmed as the most distressing to caregivers. In another, the rates of caregiver depression were high (75%) among those caring for clinically depressed AD patients. Indeed, in a third study, 100% of patients with depression had depressed caregivers. The vulnerability of caregivers to depression is linked to their own age, gender, physical ability, personality, and available social supports. Alleviation of caregiver distress, burden, and depression will be of great value in the improvement of AD patient care.
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Affiliation(s)
- L Teri
- Department of Psychiatry and Behavioral Science, University of Washington, Seattle 98195, USA
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Teri L, McCurry SM, Logsdon RG. Memory, thinking, and aging. What we know about what we know. West J Med 1997; 167:269-75. [PMID: 9348759 PMCID: PMC1304543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cognition is the foundation that underlies all daily activities, from the most basic to the most complex. Successful aging depends, in large part, on maintaining a level of cognitive ability that allows a person to interact effectively and appropriately with the environment. In the following article we provide an overview of the effects of aging on cognition; discuss physical, social, and psychological factors that have been shown to influence cognition in old age; and review current literature on interventions that may optimize successful cognitive aging. We conclude with a discussion of abnormal cognitive aging and review current research on risk factors and treatments of Alzheimer's disease and other dementing illnesses.
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Affiliation(s)
- L Teri
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle 98195-6560, USA.
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O'Meara ES, Kukull WA, Sheppard L, Bowen JD, McCormick WC, Teri L, Pfanschmidt M, Thompson JD, Schellenberg GD, Larson EB. Head injury and risk of Alzheimer's disease by apolipoprotein E genotype. Am J Epidemiol 1997; 146:373-84. [PMID: 9290497 DOI: 10.1093/oxfordjournals.aje.a009290] [Citation(s) in RCA: 117] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Head injury and apolipoprotein E (APOE)-epsilon 4 (e4) genotype have each been associated with increased risk of Alzheimer's disease. If APOE-e4 affects neuronal viability and branching, and if response to head injury differs in e4 patients, then the association between head injury and Alzheimer's disease may vary with the presence of the e4 allele. The authors examined this association in a case-control study conducted between 1987 and 1995 among enrollees of the Group Health Cooperative of Puget Sound, a health maintenance organization in Seattle, Washington. Proxy informants reported prior head injury with loss of consciousness for 32 of 349 patients with probable Alzheimer's disease and for 16 of 342 control subjects of similar age and sex who had been randomly selected from the same population (odds ratio (OR) = 2.1, 95% confidence interval (CI) 1.1-3.8). Elevated risk was observed among men (OR = 4.2, 95% CI 1.5-11.5) but not among women (OR = 1.1, 95% CI 0.5-2.6). No significant variation in the head injury-Alzheimer's disease risk relation by APOE-e4 genotype was found among 230 cases and 309 controls (OR = 3.1 (95% CI 0.7-14.6) for persons with at least one e4 allele and OR = 2.0 (95% CI 0.8-5.2) for those without e4). Neither age, education, race, type of proxy informant, nor duration of relationship with the proxy confounded the association. Head injury with loss of consciousness, although uncommon in this sample, was associated with increased risk of Alzheimer's disease. APOE-e4 was an independent risk factor which neither modified nor confounded the association. Susceptibility to Alzheimer's disease as conferred by APOE-e4 does not appear to increase the risk associated with head injury.
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Affiliation(s)
- E S O'Meara
- Department of Epidemiology, School of Public Health and Community Medicine, University of Washington, Seattle 98195, USA
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Affiliation(s)
- S M McCurry
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle 98195-6560, USA
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Teri L, Logsdon RG, Uomoto J, McCurry SM. Behavioral treatment of depression in dementia patients: a controlled clinical trial. J Gerontol B Psychol Sci Soc Sci 1997; 52:P159-66. [PMID: 9224439 DOI: 10.1093/geronb/52b.4.p159] [Citation(s) in RCA: 453] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The current study is a controlled clinical investigation of two nonpharmacological treatments of depression in patients with Alzheimer's disease. Two active behavioral treatments, one emphasizing patient pleasant events and one emphasizing caregiver problem solving, were compared to an equal-duration typical care condition and a wait list control. Seventy-two patient-caregiver dyads were randomly assigned to one of four conditions and assessed pre-, post-, and at 6-months follow-up. Patients in both behavioral treatment conditions showed significant improvement in depression symptoms and diagnosis as compared with the two other conditions. These gains were maintained at 6-month follow-up. Caregivers in each behavioral condition also showed significant improvement in their own depressive symptoms, while caregivers in the two other conditions did not. Results indicate that behavioral interventions for depression are important and effective strategies for treating demented patients and their caregivers.
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Affiliation(s)
- L Teri
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, USA
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Abstract
BACKGROUND The diagnosis of dementia requires both memory loss and at least one other type of cognitive impairment. The natural history of patients with severe memory loss but no other type of cognitive impairment is poorly understood. We studied progression to dementia in patients with isolated memory loss. METHODS From a registry of 811 patients with cognitive complaints, 21 patients with severe isolated memory loss of unknown cause were identified and followed up for a mean of 48 months. A comparison group of 198 patients on the same register was identified with newly recognised cognitive complaints but without dementia or isolated memory loss (mean follow-up 31 months). We did a range of neuropsychological tests at intake. FINDINGS During follow-up, 48% (n = 10) of patients with isolated memory loss-developed dementia compared with 18% (n = 36) of the comparison group. Life-table analysis showed the mean times to a diagnosis of dementia was 3.77 years (95% CI 2.99-4.56) and 5.96 years (5.60-6.31), respectively (p = 0.01). The neuropsychological tests did not predict which patients would progress to dementia. INTERPRETATION Patients with severe isolated memory loss have an increased risk of developing dementia and should be closely followed-up.
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Affiliation(s)
- J Bowen
- Department of Neurology, University of Washington, Seattle, USA
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Logsdon RG, Teri L. The Pleasant Events Schedule-AD: psychometric properties and relationship to depression and cognition in Alzheimer's disease patients. Gerontologist 1997; 37:40-5. [PMID: 9046704 DOI: 10.1093/geront/37.1.40] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The Pleasant Events Schedule-AD (PES-AD) has been described as a useful tool for identifying pleasant activities for Alzheimer's disease patients. The current investigation provides psychometric data on the PES-AD, introduces a shortened, 20-item version, and examines the relationship between pleasant events, cognitive functioning, and depression. Both versions of PES-AD had good reliability and were significantly correlated with each other and with other relevant measures. As hypothesized, both depression and decreased cognitive functioning were associated with reduced frequency of enjoyable activity, and the reduction was significantly greater in AD patients who were depressed than in those who were not depressed, regardless of cognitive level.
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Affiliation(s)
- R G Logsdon
- University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, Seattle 98195-6560, USA.
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O'Meara ES, Kukull WA, Schellenberg GD, Bowen JD, McCormick WC, Teri L, Pfanschmidt M, Thompson JD, Larson EB. Alzheimer's disease and history of blood transfusion by apolipoprotein-E genotype. Neuroepidemiology 1997; 16:86-93. [PMID: 9057170 DOI: 10.1159/000109675] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Some dementias, such as Creutzfeldt-Jakob disease, may result from transmissible agents. To assess the possibility of a blood-borne transmissible agent in Alzheimer's disease (AD), we compared informant-reported history of blood transfusions among 326 newly recognized probable AD cases and 330 control subjects of similar age and sex, randomly selected from the same health maintenance organization population. Since risk of AD is increased in persons with apolipoprotein E epsilon 4 (APOE-e4) alleles, we examined whether the transfusion-AD relationship varies by APOE genotype. Transfusion was more frequent among controls (17.9%) than cases (12.0%) in the overall group (crude odds ratio = 0.62; 95% confidence interval = 0.40, 0.97). Similar risks were seen for transfusions occurring < or = or > 10 years before the reference year. Stratified analysis by APOE-e4 genotype showed no effect modification. Logistic regression adjusting for age, sex, education, and presence of e4 did not change the transfusion-AD association. We conclude that a history of blood transfusion is not associated with increased risk of AD, nor does consideration of APOE-e4 status modify that conclusion.
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Affiliation(s)
- E S O'Meara
- Department of Epidemiology, University of Washington, Seattle 98195, USA
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Kukull WA, Schellenberg GD, Bowen JD, McCormick WC, Yu CE, Teri L, Thompson JD, O'Meara ES, Larson EB. Apolipoprotein E in Alzheimer's disease risk and case detection: a case-control study. J Clin Epidemiol 1996; 49:1143-8. [PMID: 8826994 DOI: 10.1016/0895-4356(96)00195-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The objective of this study was to describe the association between the epsilon 4 allele of the apolipoprotein E gene (APOE E4) and Alzheimer's disease (AD) and to evaluate APOE E4 genotyping as a test for AD. The study base of this case-control study included about 23,000 persons 60 year of age or greater (a large health maintenance organization); the demographic characteristics of this group are similar to those of the surrounding area. Analysis focused on 234 Caucasian probable AD patients first identified between 1987 and 1993; and 304 cognitively intact controls of similar age, sex, and race who were randomly selected from the same study base. All cases were examined and diagnosed by study physicians using standard protocols. All subjects participate in continuing annual follow-up testing to verify their cognitive status. APOE genotypes were determined from blood samples using standard laboratory methods. Subject characteristics and diagnoses were obtained from interviews, diagnostic examination, or medical record review. Heterozygous E4 individuals had a crude odds ratio of 3.1 (2.1-4.5) for AD compared to those with no E4, while homozygous E4 subjects had an odds ratio of 34.3 (8.0-146.3) for AD. As an indicator of AD, having one E4 allele showed a sensitivity of 0.52 and a specificity of 0.74. Homozygous E4 genotype had a sensitivity of 0.23 and a specificity of 0.99 (when compared to non-E4 genotypes). Cardiovascular disease differed in cases and controls, but did not confound or modify the APOE E4-AI) association. In this study base, the APOE E4 allele was a significant risk factor. However, considering either homozygous or heterozygous E4 genotype as a screen or diagnostic marker for AD would miss many true cases and could misclassify many normals as AD.
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Affiliation(s)
- W A Kukull
- Department of Epidemiology, University of Washington, Seattle 98195, USA
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Bowen JD, Malter AD, Sheppard L, Kukull WA, McCormick WC, Teri L, Larson EB. Predictors of mortality in patients diagnosed with probable Alzheimer's disease. Neurology 1996; 47:433-9. [PMID: 8757016 DOI: 10.1212/wnl.47.2.433] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE We sought to identify factors associated with mortality in persons recently diagnosed with probable Alzheimer's disease (AD). BACKGROUND Predicting mortality in AD in needed both in patient care and public health planning. Previous studies have identified several factors which contribute to mortality in AD, but few longitudinal studies of population-based cohorts exist. METHODS In a longitudinal follow-up study 327 patients with newly diagnosed probable AD (mean Mini-Mental State Examination [MMSE] score of 20) from a large, stable health maintenance organization were identified. Demographic characteristics, dementia severity, and comorbid conditions were identified at enrollment. Patients were followed longitudinally (median 3.3 years, total 898 person-years). Baseline characteristics were used to predict survival in univariate and multivariate models. RESULTS Increased mortality was seen in patients with probable AD (9.0 deaths per 100 person-years) compared with the community population adjusted for age and gender (4.3 deaths per 100 person-years). On univariate analysis we found increased age, male gender, impairment on MMSE or Blessed dementia rating scale (DRS), rate of MMSE decline, wandering or agitation, vascular disease, and sensory impairment affecting the ability to read or hear to be moderately associated with decreased survival. After adjusting for age and gender in a multivariate model, Blessed DRS score and sensory impairment affecting the ability to read were independently associated with decreased survival. CONCLUSIONS Short-term mortality is increased in patients newly diagnosed with probable AD. Measures of dementia severity, measures of general debility, and vascular disease are associated with increased mortality. Of these, general debility and sensory impairment were more strongly associated with shortened survival.
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Affiliation(s)
- J D Bowen
- Department of Medicine, University of Washington, Seattle, USA
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47
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Teri L. 187 Behaviour and caregiver burden: Behavioural problems in patients with Alzheimer's disease and its association to caregiver burden. Neurobiol Aging 1996. [DOI: 10.1016/s0197-4580(96)80189-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
The usefulness of data generated by clinical trials of patients with behavioral disturbances of dementia depends heavily on the study design and the measures used to determine patient outcomes. Several rating scales are available to assess general behavioral problems, agitation, and depression in patients with dementia. The appropriate rating tool depends not only on the purpose of the study but also on whether the measure meets the criteria discussed subsequently.
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Affiliation(s)
- L Teri
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
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49
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Barnhart RL, van Belle G, Edland SD, Kukull W, Borson S, Raskind M, Teri L, McLean P, Larson E. Geographically overlapping Alzheimer's disease registries: comparisons and implications. J Geriatr Psychiatry Neurol 1995; 8:203-8. [PMID: 8561832 DOI: 10.1177/089198879500800401] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In the medical and epidemiologic literature, a registry denotes a data base in which registrants share some common characteristic such as disease category. One criticism of registries is that they frequently collect subjects in a haphazard fashion and, hence, are "nonrepresentative of the population purportedly being represented." In this report, we compare two registries: an incident-based Alzheimer's Disease Patient Registry (ADPR) recruiting subjects for epidemiologic studies from a large health maintenance organization; and an Alzheimer's Disease Research Center (ADRC) registry recruiting subjects for phenomenologic, biologic, and pharmacologic studies. While these registries share personnel, overlap geographically, and use similar diagnostic procedures, they differ substantially in their missions and resulting recruitment strategies. We compared these registries with respect to demographic characteristics and cognitive features at subject entry. Subjects enrolled in the incident-based registry are older and report shorter time between symptom onset and recruitment. They are less demented and mirror the general population demographically more closely than do subjects in the other registry. The ADRC registry contains a much greater proportion of subjects with higher educational attainment.
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Affiliation(s)
- R L Barnhart
- Department of Pathology, University of Washington, Seattle 98105-6099, USA
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Abstract
Selecting outcome measures that are both psychometrically sound and sensitive to change is a very important aspect of clinical outcome research. A variety of measures have been introduced in recent years to assess behavioral complications in dementia, but few have been adequately tested in clinical trials. This article provides a discussion of factors to consider in selecting measures, including psychometrics, item content, assessment source, and sensitivity to change. A review of behavioral and psychiatric measures for dementia patients is provided, including measures of general behavioral disturbance, and measures specifically developed for agitation and depression. Each measure's psychometric characteristics, prior use with demented patients, and strengths and weaknesses with regard to treatment outcome research is summarized. The importance of linking measures to the investigators' hypotheses is discussed, along with recommendations for evaluating and selecting outcome measures depending on the needs of the specific investigation.
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Affiliation(s)
- L Teri
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle 98195, USA
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