Risk assessment of wandering behavior in mild dementia

OBJECTIVE

This prospective longitudinal study aims to determine the risk factors of wandering-related adverse consequences in community-dwelling persons with mild dementia. These adverse consequences include negative outcomes of wandering (falls, fractures, and injuries) and eloping behavior.

METHODS

We recruited 143 dyads of persons with mild dementia and their caregivers from a veteran's hospital and memory clinic in Florida. Wandering-related adverse consequences were measured using the Revised Algase Wandering Scale - Community Version. Variables such as personality (Big Five Inventory), behavioral response to stress, gait, and balance (Tinetti Gait and Balance), wayfinding ability (Wayfinding Effectiveness Scale), and neurocognitive abilities (attention, cognition, memory, language/verbal skills, and executive functioning) were also measured. Bivariate and logistic regression analyses were performed to assess the predictors of these wandering-related adverse consequences.

RESULTS

A total of 49% of the study participants had falls, fractures, and injuries due to wandering behavior, and 43.7% demonstrated eloping behaviors. Persistent walking (OR = 2.6) and poor gait (OR = 0.9) were significant predictors of negative outcomes of wandering, while persistent walking (OR = 13.2) and passivity (OR = 2.55) predicted eloping behavior. However, there were no correlations between wandering-related adverse consequences and participants' characteristics (age, gender, race, ethnicity, and education), health status (Charlson comorbidity index), or neurocognitive abilities.

CONCLUSION

Our results highlight the importance of identifying at-risk individuals so that effective interventions can be developed to reduce or prevent the adverse consequences of wandering.

Assessment of Diagnostics Tools for Sarcopenia Severity Using the Item Response Theory (IRT)

OBJECTIVE

To use the item response theory (IRT) methods to examine the degree to which the four selected tools reflect sarcopenia and to arrange them according to their ability to estimate sarcopenia severity.

DESIGN

A cross-sectional study aimed at verifying the possibilities of using diagnostic tools for sarcopenia.

SETTING AND PARTICIPANTS

The study included residents living in an assisted living unit at the Senior Centre in Blansko (South Moravia, Czech Republic) (n=77). Sarcopenia was estimated according to the proposals of the European Working Group on Sarcopenia in Older People (EWGSOP) using calf circumference, the EWGSOP algorithm, hand grip strength, and the Short Physical Performance Battery (SPPB).

RESULTS

The results from the IRT model showed that these four methods indicate strong unidimensionality so that they measure the same latent variable. The methods ranked according to the discrimination level ranging from high to low discrimination where the calf circumference was the most discriminatory (Hi = 0.86) and the SPPB together with hand grip strength were the least discriminatory (both Hi = 0.44).

CONCLUSION

We are recommending to identify mild sarcopenia by SPPB or hand grip strength, moderate sarcopenia by the EWGSOP algorithm and severe sarcopenia by the calf circumference.

Severe impairment of circadian rhythm in Alzheimer's disease

Circadian rhythmicity was repeatedly determined in a patient with Alzheimer's disease by measuring his core temperature with a rectal thermistor and motor activity by an ambulatory activity monitor. The first recording, performed 9 years after he was diagnosed with Alzheimer's disease, showed well organized 24 hr circadian rhythm of core body temperature. The second recording, made four months later, showed very poor fit of core body temperature to 24 hour rhythm, but excellent fit with 36 hour rhythm. The third recording, made two months later, showed again good fit of core body temperature with 24 hour cycle. The last recording, which was performed 5 months later, showed almost complete disappearance of circadian rhythm of body temperature. These changes probably reflect gradual lengthening of the circadian cycle that at one point became extremely lengthened before returning to the 24 hr cycle.

Goals of care in advanced dementia: quality of life, dignity and comfort

Prolongation of human lifespan is increasing the number of individuals suffering from Alzheimer's disease and other progressive dementia worldwide. There are about 5 million of these individuals in both United States and European Union and many more in other countries of the world (1). Because there is no curative treatment for these diseases, most individuals with dementia survive to an advanced stage of dementia at which time many of them require institutional care. Home care for individuals with advanced dementia and especially institutional care are very expensive and are becoming major public health problems. The cost of care for advanced dementia is often increased by the use of aggressive medical interventions that may not be in the best interest of the patient. Because advanced dementia is currently incurable, it should be considered a terminal illness, similar to terminal cancer. Therefore, palliative care may be the most appropriate strategy for management of advanced dementia (2). The goals of palliative care are maintenance of quality of life, dignity and comfort and the four articles in this special issue are addressing these goals. Enhancement of quality of life in dementia requires attention to three main domains: provision of meaningful activities, appropriate medical care, and treatment of behavioral symptoms (3). Individuals with advanced dementia may not be able to participate in many activity programs but they still may maintain some quality of life if they are provided care in a pleasant environment with constant presence of a caregiver. Simard describes a program, Namaste Care, which is specifically tailored for individuals with advanced dementia. This program requires neither major expenditure nor increased staffing and should be instituted in all facilities that care for individuals with advanced dementia. Maintaining functional status of individuals with advanced dementia is important because it improves their self esteem and facilitates provision of care. Van der Steen et al. present evidence that lower respiratory tract infection leads frequently but not always to functional decline. However, it is significant that the Dutch participants in this study were never hospitalized and always treated in a nursing home. Hospitalization leads to functional deterioration even in cognitively intact elderly individuals (4). In addition, treatment of lower respiratory infection is more effective when provided in a nursing home than when the resident is transferred to an acute care setting (5). It should also be considered that antibiotic treatment of lower respiratory tract infections in individuals with terminal dementia does not increase their comfort and lifespan (6). Dignity is an often invoked goal of care in dementia but it is often poorly defined and characterized. Holmerova et al. provide a detailed description of the concept of dignity and its application in dementia care. They also present two specific examples of problems encountered when individuals with advanced dementia are treated insensitively in an acute care setting. Dignity oriented care should treat everybody as an individual and provide care according to the goals of care determined before any crisis situation (7). Namaste Care is an example of care setting that respects individual's dignity until death; respecting "the spirit within". Tube feeding in individuals with advanced progressive dementia does not promote quality of life, dignity or comfort. Tube feeding deprives individuals from contact with the caregiver during hand feeding and from enjoyment of the taste of food. Tube feeding often requires use of restraints that decreases an individual's dignity and comfort. Despite the lack of beneficial effects and the burdens that the tube feeding imposes (8), it is still widely used in individuals with advanced dementia. Pang et al. compare the use of tube feeding in two different settings of dementia care, one in which tube feeding is not used and one in which everybody dies with some form of artificial feeding. She documents that the main reason for this difference is varying attitudes of medical staff and not different perceptions of best interest of the patient as expressed by the patient's relatives. It is hoped that this special issue will increase awareness of the medical community about appropriateness of palliative care for individuals with advanced dementia. Such care may not only provide better care for individuals with dementia and their families but may also save some health care resources (9). Palliative care is well accepted by many relatives of individuals with advanced dementia but not promoted by many health care professionals. We need to provide more education and research results for health care professionals to increase the use of palliative care in advanced dementia.

Comparing the ethical challenges of forgoing tube feeding in American and Hong Kong patients with advanced dementia

OBJECTIVES

To develop a cross-cultural dialogue for enriching our understanding of how an ethical environment can be constructed in fostering tube-feeding decisions in patients with advanced dementia (AD).

DESIGN AND DATA SOURCE

Drawing on the findings of two prospective case studies conducted in Boston and Hong Kong, this paper compares the decision-making patterns of forgoing tube feeding for AD patients and their emergent ethical dilemmas typified in a special dementia care unit in Boston (BCU) and a long-term care unit in Hong Kong (HKCU).

FINDINGS

Differences in forgoing tube feeding decision are delineated in the two places. No-tube-feeding practice was sustained in BCU in two ways: advance decision-making with respect paid to the patient's wishes and advance proxy decision-making focused on patient comfort. With life preservation as the prevailing value in the Hong Kong medical system, only strong family request coupled with medical evidence of patient's ability to continue hand-feeding that tube feeding would be discontinued. All patients died with some form of artificial feeding.

CONCLUSION

A paradigm shift of values underpinning the practice of forgoing tube feeding in the context of palliative care is observed in three aspects. First, the emphasis on prognostication based on biomedical markers in predicting the length of survival is shifted to a focus on the "diagnosis of dying". Second, the overriding concern in conventional medical practice with preserving life is shifting to an overriding concern of "what is best for the patient." Third, in the last days of life, the conventional approach of "trying to do everything for the patient" had shifted from a technological to a relational one. Palliative measures for relieving discomfort and providing a peaceful and dignified environment in which the patient could die are the primary concern. Although the predominant medical culture in Hong Kong is biomedical, voices from the patients and family members challenge this conventional practice, and suggest that the alternative model may be a better choice.

Dementia

Alzheimer's disease is the most common cause of dementia, but often several other conditions causing dementia are present on brain autopsies. Palliative care medical issues are similar in all late stage progressive degenerative dementias and include; cardiopulmonary resuscitation, transfer to acute care setting, antibiotic therapy, and tube feeding. Behavioral symptoms of dementia include agitation and resistiveness to care. Quality of life of individuals suffering from dementia is enhanced by availability of meaningful activities and by avoidance of restraints. Family support and involvement are crucial for optimal care. Formulation of advanced directives or an advance proxy plan is important for assuring the patient's previous wishes or best interests are considered when decisions about treatment strategies are made.

Scales for evaluation of End-of-Life Care in Dementia

Systematic evaluation of end-of-life care in dementia has been hampered by a lack of instruments to specifically address those issues that are unique for persons who are dying with dementia. This study evaluated psychometric properties of three scales designed to measure outcomes of care of persons suffering from terminal dementia. A survey of family caregivers whose loved one died during the past year was conducted using a questionnaire that included questions regarding satisfaction with care, physical and emotional symptoms that occurred during the last 90 days of the care recipient's life, and comfort during the dying process. Three scales were developed based on responses from 156 questionnaires: Satisfaction with Care at the End-of-Life in Dementia (SWC-EOLD), Symptom Management at the End-of-Life in Dementia (SM-EOLD) with Physical and Psychological Symptoms subscales, and Comfort Assessment in Dying with Dementia (CAD-EOLD) with four subscales: Physical Distress, Dying Symptoms, Emotional Distress, and Well Being. The three scales developed and evaluated in this study can be used as outcome measures in studies investigating effectiveness of interventions aimed to improve end-of-life care for individuals with dementia.

Management of severe Alzheimer's disease and end-of-life issues

The quality of life of individuals with severe Alzheimer's disease requires attention to three main factors: (1) availability of meaningful activities, (2) optimal management of medical issues, and (3) appropriate treatment of psychiatric symptoms. Preservation of ambulation and comfort and avoidance of depression are significant interfaces between these three main factors. Formulation of an advance proxy plan is important for ensuring that the patient's previous wishes or best interests are considered when decisions about treatment strategies are made. Decisions regarding treatment strategies should take into consideration decreased effectiveness of several therapeutic approaches in this patient population. Hospice care is appropriate for the terminal stage of Alzheimer's disease, but palliative care also can be provided in other settings.

Sundowning and circadian rhythms in Alzheimer's disease

OBJECTIVE

The goal of this study was to determine changes of circadian rhythms induced by Alzheimer's disease and to explore relationships among rhythm disturbances, sundowning, and sleep disturbances in patients with Alzheimer's disease. "Sundowning" is the occurrence or exacerbation of behavioral symptoms of Alzheimer's disease in the afternoon and evening.

METHOD

Circadian rhythms of core body temperature and motor activity were measured in 25 patients with diagnoses of probable Alzheimer's disease and in nine healthy individuals. The subjects with Alzheimer's disease were divided according to the occurrence of sundowning as determined by staff reports.

RESULTS

The subjects with Alzheimer's disease had less diurnal motor activity, a higher percentage of nocturnal activity, lower interdaily stability of motor activity, and a later activity acrophase (time of peak) than did the healthy individuals. They also had a higher mesor (fitted mean) temperature, higher amplitude of the fitted cosine temperature curve, and later temperature acrophase than did the healthy subjects. The severity of sundowning was associated with later acrophase of temperature, less correlation of circadian temperature rhythm with a 24-hour cycle, and lower amplitude of temperature curve.

CONCLUSIONS

These data indicate that Alzheimer's disease causes disturbances of circadian rhythms and that sundowning is related to a phase delay of body temperature caused by Alzheimer's disease.

Target outcomes for long-term oral health care in dementia: a Delphi approach

This study developed a list of target outcomes for long-term oral health care in persons with dementia. A three-round Delphi study was used to develop a list of target outcomes. Participants included 99 staff and 171 family members associated with the Dementia Special Care Unit in Bedford, MA. In Round 1 participants were asked to list five outcomes for long-term oral health care. Items were grouped, redundancies removed, and fed back in Round 2, when participants scored the items from 1 (least important) to 10 (most important). Round 2 responses were tabulated and the top 20 were fed back for scoring in Round 3. The top 10 target outcomes in decreasing order of importance were: patient will be free from oral pain, patient will not be at risk for aspiration, emergency dental treatment will be available when needed, prevent mouth infections, daily mouth care is as much a part of daily care as shaving or brushing hair, prevent discomfort from loose teeth or sore gums, teeth will be brushed thoroughly once a day, staff will be able to provide oral hygiene care as needed, provide dental care to prevent problems eating, and recognize oral problems early. Family and professional caregivers were remarkably consistent in their identification of the top 10 outcomes. Further work is needed to ensure broad international and interdisciplinary acceptance (including families and the long-term care residents themselves) of target outcomes for long-term oral health care in persons with dementia.

Differential circadian rhythm disturbances in men with Alzheimer disease and frontotemporal degeneration

BACKGROUND

Caregiver exhaustion is a frequent consequence of sleep disturbance and rest-activity rhythm disruption that occurs in dementia. This exhaustion is the causal factor most frequently cited by caregivers in making the decision to institutionalize patients with dementia. Recent studies have implicated dysfunction of the circadian pacemaker in the etiology of these disturbances in dementia.

METHODS

We studied the activity and core-body temperature rhythms in a cohort of 38 male patients with a clinical diagnosis of probable Alzheimer disease (AD) approximately 2 years before death. These patients were later given a confirmed diagnosis of AD (n = 23), frontotemporal degeneration (FTD) (n = 9), or diffuse Lewy body disease (DLB) with mixed AD or FTD pathologies (n = 6) after autopsy and neuropathological examination. Physiological rhythms of patients with AD and FTD were then compared with a group of normal, elderly men (n = 8) from the community.

RESULTS

Alzheimer patients showed increased nocturnal activity and a significant phase-delay in their rhythms of core-body temperature and activity compared with patients with FTD and controls. The activity rhythm of FTD patients was highly fragmented and phase-advanced in comparison with controls and apparently uncoupled from the rhythm of core-body temperature.

CONCLUSIONS

Patients with AD and patients with FTD show different disturbances in their rhythms of activity and temperature compared with each other and with normal elderly patients.

Effect of decreased mobility on body composition in patients with Alzheimer's disease

Randomly selected 50 patients with the diagnosis of probable Alzheimer's disease, hospitalized for long-term care in a Special Care Dementia unit, were examined. None of the patients were clinically malnourished although several had low cholesterol levels. The mean lean body mass, measured by bioelectrical impedance plethysmography, was 62.5% of total body mass. The average calorie intake was 2125+398 Kcal/day, ranging from 1300 to 2900 Kcal/day, and the body weight of most subjects was stable, with the average gain of 1 lbs in the previous three months. Eighteen patients ambulated independently, 14 required assistance, and 18 were non-ambulatory. The lean body mass index was associated with the patient's age and mobility status. These results indicate that patients with advanced dementia and compromised mobility have decreased muscle mass that may result in weight loss even in the absence of malnutrition.

Head injury and the risk of AD in the MIRAGE study

OBJECTIVES

It has been suggested in some studies that head injury is a risk factor for AD, and that this risk is heightened among carriers of the APOE-epsilon4 allele. We examined the effects of head injury and APOE genotype on AD risk in a large family study.

SUBJECTS

A total of 2,233 probands who met criteria for probable or definite AD and their 14,668 first-degree family members (4,465 parents, 7,694 siblings, and 2,509 spouses) were ascertained at 13 centers in the United States, Canada, and Germany participating in the MIRAGE (Multi-Institutional Research in Alzheimer Genetic Epidemiology) project. Information on head injury was collected by interview of multiple informants and review of medical records. Nondemented relatives and spouses served as control subjects for this study.

METHODS

Odds of AD for head trauma with or without loss of consciousness were computed by comparing probands with unaffected spouses using conditional logistic regression analysis. To account for the unique biologic relationship between probands and their parents and siblings, odds of AD were computed using a generalized estimating equation (GEE) Poisson regression approach. GEE logistic regression was used to examine the joint effects of APOE genotype and head injury on the odds of AD in probands and a control group comprised of unaffected siblings and spouses.

RESULTS

Comparison of probands with their unaffected spouses yielded odds ratios for AD of 9.9 (95% CI, 6.5 to 15.1) for head injury with loss of consciousness and 3.1 (2.3 to 4.0) for head injury without loss of consciousness. The corresponding odds derived from the comparison of probands with their parents and sibs were 4.0 (2.9 to 5.5) for head injury with loss of consciousness and 2.0 (1.5 to 2.7) for head injury without loss of consciousness. Head injury without loss of consciousness did not significantly increase the risk of AD in spouses (OR = 1.3; 95% CI, 0.4 to 4.1). The joint effects of head injury and APOE genotype were evaluated in a subsample of 942 probands and 327 controls (spouses and siblings). Head injury increased the odds of AD to a greater extent among those lacking epsilon4 (OR = 3.3) than among epsilon4 heterozygotes (OR = 1.8) or homozygotes (OR = 1.3).

CONCLUSION

Head injury is a risk factor for AD. The magnitude of the risk is proportional to severity and heightened among first-degree relatives of AD patients. The influence of head injury on the risk of AD appears to be greater among persons lacking APOE-epsilon4 compared with those having one or two epsilon4 alleles, suggesting that these risk factors may have a common biologic underpinning.

Dimensions of decreased psychological well-being in advanced dementia

Evaluation of psychological well-being among persons with an advanced dementia is primarily dependent on verbal and non-verbal cues and behaviors that are observed and interpreted by others. The purpose of the present study was to determine how many components of psychological well-being can be measured. Fifty-seven individuals who were institutionalized for advanced dementia and exhibited agitation or withdrawal were evaluated by direct observations and by interviews with nursing home staff. Engagement was measured by the Lawton Positive Affect scale, visual analog scale, and reported degree of patient's interest in the environment. Mood was measured by a global indicator of mood interpreted from facial expression and two mood items from the Multidimensional Observation Scale for Elderly Subjects. Agitation was measured by a visual analog scale and by the Short Form of the Cohen-Mansfield Agitation Inventory. Correlation analyses and multidimensional scaling provided evidence for three dimensions of psychological well-being: engagement-apathy, happy sad mood, and calm-agitation. Evaluation of these three dimensions is important for measuring quality of care in long-term care settings and for determining effectiveness of therapeutic interventions.

PC12 cells transfected with a C-terminal fragment of the amyloid precursor protein (APP C-100), exhibit enhanced sensitivity to the calcium ionophore A23187, and diminished sensitivity to hydrogen peroxide

Extracellular neuritic plaques are a hallmark of Alzheimer's disease. The core protein of plaques is Abeta, a 39-43 amino acid peptide derived from the amyloid precursor protein (APP). APP C-100 is a C-terminal fragment of APP, 100 amino acids long, whose sequence includes Abeta. To determine whether APP C-100 expression alters cellular vulnerability to calcium and H(2)O(2), rat PC12 cells were modified to overexpress APP C-100. Cellular survival (as measured in the MTT assay) was determined as a function of concentration for the calcium ionophore, A23187, and for H(2)O(2) in APP C-100 transfectants and vector-transfected controls. APP C-100 expression significantly increased cellular vulnerability to A23187, and decreased vulnerability to H(2)O(2).

Enhanced inhibition of free radical-induced deoxyribose breakdown by Alzheimer brain homogenates

The ability of homogenates from Alzheimer and control brains to inhibit formation of thiobarbituric acid reactive products (TBAR) induced by free radicals was compared. The assay for TBAR was modified by adding 1% sodium dodecyl sulfate (SDS) to prevent chromogen adsorption by biological matrices, and by extending the incubation time. The inhibitory activities required smaller equivalents of Alzheimer brain homogenates than control homogenates. Similar inhibitory activities were seen in homogenates from amygdala, temporal cortex and cerebellum. The inhibitory activities were similar in brain homogenates from individuals with different apolipoprotein E status. These results indicate that Alzheimer brain tissue has either increased content of free radical scavengers or is more sensitive to free radical attack than control brains.

Evaluation of Simulated Presence: a personalized approach to enhance well-being in persons with Alzheimer's disease

OBJECTIVE

To evaluate the efficacy of Simulated Presence, a personalized approach to enhance well-being among nursing home residents with Alzheimer's disease and related dementia's (ADRD).

DESIGN

Latin-Square, double blinded, 3-factor design with restrictive randomization of three treatments (the study intervention, a placebo audio tape of a person reading the newspaper, and usual care). The three factors were treatment, time, and facility type.

SETTING

Nine nursing homes in Eastern Massachusetts and Southern New Hampshire.

PARTICIPANTS

Fifty-four subjects with documented ADRD who were aged 50 years or older, medically stable, had resided in their current nursing home for at least 3 months, and who had no planned discharge. All subjects had a history of agitated or withdrawn behaviors.

INTERVENTION

The purpose of Simulated Presence is to provide a personalized intervention for persons with moderate to severe cognitive impairment. Through a unique testing process, some of the best loved memories of the ADRD person's lifetime are identified and then those memories are introduced to the patient in the format of a telephone conversation using a continuous play audio tape system. The intervention may be used for extended periods of time because each repetition is viewed as a fresh, live telephone call as a result of the short-term memory deficit of the person with ADRD.

MEASUREMENTS

Direct observations of outcomes included using a newly developed scale, the Scale for the Observation of Agitation in Persons with Dementia, an agitation visual analog scale, the Positive Affect Rating Scale (mood and "interest"), a withdrawal visual analog scale, and facial diagrams of mood. Reported measures included daily staff observation logs of responses to interventions offered, and weekly staff surveys using the short-form Cohen-Mansfield Agitation Inventory and the Multidimensional Observation Scale for Elderly Subjects (mood and "interest"). Severity of dementia was assessed by the Mini-Mental State Exam, the Test for Severe Impairment, the Bedford Alzheimer's Nursing Scale, and the ADL Self-Performance Scale.

RESULTS

Chi-square analysis of direct observations, using facial diagrams, revealed that Simulated Presence was equivalent to usual care (P = .141) and superior to placebo for producing a happy facial expression (P = .001). A positive effect was also documented in nursing staff observation logs using Analysis of Variance techniques (ANOVA) for subjects during Simulated Presence phases compared with the placebo phases (P < .001) and usual care phases (P < .001). According to ANOVA analyses of "interest" from weekly surveys, Simulated Presence was superior to both usual care (P = .001) and placebo (P = .008). We were unable to find evidence of significant differences (P < .05) among interventions for other direct observations and weekly reports of overall agitation or mood aspects of withdrawal. Subjects accepted the intervention most of the time, except for five subjects who refused it more than 50% of the time.

CONCLUSION

This study provided evidence that Simulated Presence can be effective in enhancing well-being and decreasing problem behaviors in the nursing home setting as a substitute for or complement to usual care.

Assessment of behavioral symptom management in demented individuals

This article is intended to stimulate interdisciplinary research by social, behavioral, and biomedical researchers to solve some of the problems for persons with Alzheimer disease who suffer from behavioral symptoms. We identify the need for using conceptually based measures that have adequate reliability and validity to operationalize indicators of psychological well-being, suggest instruments to assess mood, engagement, agitation, resistiveness and comfort, and pose research questions to explore responses to active involvement (individual or group), passive involvement, lack of activity, aversive activity (related to activities of daily living), and limitation of activity (restraints) in persons with dementia. Answers to the research questions posed in this article will lead to expanded knowledge and can redefine how we give care to those in need.

Development and testing of the Resistiveness to Care Scale

A conceptual model and objective scale for measuring resistiveness to care in individuals with advanced dementia of the Alzheimer type (DAT) were empirically generated from the perspective of nursing staff caregivers and through observation of residents with DAT. The resistiveness to care scale (RTC-DAT) was judged to have content validity and reduced to 13 items. Quantifiable scoring procedures and methods for rating videotapes and conducting clinical observations were developed. The RTC-DAT was tested with 68 subjects at three sites. The RTC has a range of 0-156. Initial testing provided reliability estimates of .82-.87 for internal consistency and good to excellent kappas. Criterion-related validity with observed discomfort and construct validity by factor analysis support the RTC-DAT. Measurement issues and recommendations for use in research are discussed.

Pathologic evaluation of the human suprachiasmatic nucleus in severe dementia

Sleep disruption and other circadian rhythm disturbances are frequently seen in dementia patients. In this study, we examined the suprachiasmatic nucleus (SCN), the putative site of the hypothalamic circadian pacemaker, to determine the nature and degree of pathologic changes caused by severe dementia. Neuropathologic examination indicated that among 30 patients with a clinical history of severe dementia, 22 had Braak and Braak stage V-VI Alzheimer disease, 3 had combined Alzheimer and Parkinson disease, 3 had Pick disease and 2 had severe hippocampal sclerosis. Comparisons were made with a control group composed of 13 age-matched patients with no clinical or pathological evidence of dementia or other CNS disorders. To determine the pathologic involvement within the SCN, human hypothalami were stained with: Nissl, Bielchowsky silver, thioflavin S and specific antibodies directed against vasopressin (VP), neurotensin (NT), neuropeptide Y (NPY), vasoactive intestinal peptide (VIP), beta-amyloid (B/A4) and glial fibrillary acidic protein (GFAP). Pathologic damage was primarily limited to neuronal loss and neurofibrillary tangle formation. Only rare diffuse plaques were noted. The pathologic changes within the SCN were less severe than in the other brain regions. Morphometric analysis was accomplished using a stereological approach to sample the average total number of positively stained neurons and astrocytes in 10 different 0.1mm2 microscopic fields in the dorsal subdivision of the SCN. Patients with Alzheimer disease exhibited a significant decrease in vasopressin (9.75 vs 16.7, p < 0.001) and neurotensin (6.82 vs 9.63, p < 0.002) neurons, as well as a corresponding increase in the GFAP-stained astrocyte/Nissl-stained neuron ratio (0.54 vs 0.10, p < 0.009). These studies provide evidence that both vasopressin and neurotensin neurons are lost in Alzheimer disease, and that the astrocyte/neuron ratio is a reliable indicator of disease-related pathology within the SCN. Taken collectively, our data support the hypothesis that damage to the SCN may be an underlying anatomical substrate for the clinically observed changes in circadian rhythmicity that have been observed in Alzheimer patients.

Physical status and complications in patients with Alzheimer disease: implications for outcome studies

Physical illnesses commonly coexist with dementia of the Alzheimer type (DAT). Their presence complicates DAT research because it represents a confounding variable. Furthermore, some illnesses or their symptoms also may be used as outcome measures. The conditions that frequently occur in subjects with DAT include neurological complications, intercurrent infections, and malnutrition. This review summarizes data regarding the connections among these conditions and DAT.

Persistent vegetative state in Alzheimer disease. Does it exist?

OBJECTIVE

To determine if the published criteria for diagnosis of the persistent vegetative state could be applied to patients suffering from Alzheimer disease.

DESIGN AND METHODS

Eighty-eight institutionalized patients with a diagnosis of possible or probable Alzheimer disease were evaluated for the presence of persistent vegetative state. Initial screening excluded patients who were able to do any of the following: feed themselves, respond to command, walk, or maintain continence of bowel and bladder. A sample of 12 of 28 patients unable to perform any of these functions was examined independently by 3 of us.

RESULTS

During the first examination, 2 patients were diagnosed as being in a vegetative state by 2 of us and 3 additional patients by 1 of us. One of us did not diagnose any patient as being in a vegetative state. A second evaluation of the same patients was performed 2 months later, after holding a consensus meeting to standardize the evaluation procedure. During the second evaluation, the vegetative state was diagnosed in 6 patients but only by 1 of us.

CONCLUSION

The diagnostic disagreement between the neurologists indicate that Alzheimer disease may only rarely progress to the persistent vegetative state.

Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer's disease

A placebo-controlled crossover design, with each treatment period lasting 6 weeks, was used to investigate effects of dronabinol in 15 patients with a diagnosis of probable Alzhemer's disease who were refusing food. Eleven patients completed both study periods; one patient who died of a heart attack 2 weeks before the end of the study was also included in the analysis. The study was terminated in 3 patients: one developed a grand mal seizure and 2 developed serious intercurrent infections. Body weight of study subjects increased more during the dronabinol treatment than during the placebo periods. Dronabinol treatment decreased severity of disturbed behavior and this effect persisted during the placebo period in patients who received dronabinol first. Adverse reactions observed more commonly during the dronabinol treatment than during placebo periods included euphoria, somnolence and tiredness, but did not require discontinuation of therapy. These results indicate that dronabinol is a promising novel therapeutic agent which may be useful not only for treatment of anorexia but also to improve disturbed behavior in patients with Alzheimer's disease.

Postnatal changes of brain monoamine levels in prenatally malnourished and control rats

The effects of age and prenatal protein malnutrition (6% casein diet) on the concentration of monoamine neurotransmitters and their metabolites and precursors in the hippocampal formation, striatum, brain stem and cerebral cortex were investigated in 1-, 15-, 30-, 45-, 90- and 220-day-old rats. Concentrations of all neurotransmitters, i.e. dopamine, norepinephrine and serotonin changed significantly during the development. However, two main patterns were recognized. Serotonin in all areas, and dopamine in the striatum, increased from birth to day 45, and declined significantly in 90-day-old rats. In contrast, norepinephrine in all areas, and dopamine in areas other than the striatum, showed the lowest levels in 30-day-old rats, with levels increasing gradually after this age. Concentrations of metabolites paralleled changes in corresponding neurotransmitter levels. Prenatal protein malnutrition did not significantly affect any neurotransmitter concentrations with the exception of increased tryptophan levels (181%) in the hippocampal formation of newborn rats and decreased tyrosine levels (59%) in the striatum of day 30 rats. The results indicate that the monoamine transmitter content varied dynamically throughout postnatal life; however, they seem to counteract the insult from prenatal protein malnutrition after postnatal nutritional rehabilitation.

Evidence for major gene inheritance of Alzheimer disease in families of patients with and without apolipoprotein E epsilon 4

Apolipoprotein E (APOE) genotype is the single most important determinant to the common form of Alzheimer disease (AD) yet identified. Several studies show that family history of AD is not entirely accounted for by APOE genotype. Also, there is evidence for an interaction between APOE genotype and gender. We carried out a complex segregation analysis in 636 nuclear families of consecutively ascertained and rigorously diagnosed probands in the Multi-Institutional Research in Alzheimer Genetic Epidemiology study in order to derive models of disease transmission which account for the influences of APOE genotype of the proband and gender. In the total group of families, models postulating sporadic occurrence, no major gene effect, random environmental transmission, and Mendelian inheritance were rejected. Transmission of AD in families of probands with at least one epsilon 4 allele best fit a dominant model. Moreover, single gene inheritance best explained clustering of the disorder in families of probands lacking epsilon 4, but a more complex genetic model or multiple genetic models may ultimately account for risk in this group of families. Our results also suggest that susceptibility to AD differs between men and women regardless of the proband's APOE status. Assuming a dominant model, AD appears to be completely penetrant in women, whereas only 62%-65% of men with predisposing genotypes develop AD. However, parameter estimates from the arbitrary major gene model suggests that AD is expressed dominantly in women and additively in men. These observations, taken together with epidemiologic data, are consistent with the hypothesis of an interaction between genes and other biological factors affecting disease susceptibility.

Neurotoxicity of free-radical-mediated serotonin neurotoxin in cultured embryonic chick brain neurons

Exposure of serotonin (5-HT) to oxygen-derived free-radical-generating system, xanthine oxidase-hypoxanthine or to a Fenton reaction results in the formation of the neurotoxin, tryptamine-4,5-dione. In cultured embryonic chick brain neurons, incubation of tryptamine-4,5-dione or its ethyl carbonate derivative resulted in a dose-dependent neurotoxicity (1-100 microM). The addition of sulfhydryl compound, glutathione at 2 or 10 microM significantly enhanced the toxicity induced by 10 microM tryptamine-4,5-dione. On the contrary, glutathione at 10 microM decreased the neurotoxic effect caused by 10 microM 5,6- and 5,7-dihydroxytryptamine in the cultured neurons. The toxicity resulted from 5,6- and 5,7-dihydroxytryptamine could be fully prevented by a 5-HT uptake inhibitor, fluoxetine. However, the toxicity caused by tryptamine-4,5-dione and glutathione conjugate could not be blocked by fluoxetine (10 or 100 microM) or by a glutathione transferase inhibitor, boric acid/serine. The results indicate a different molecular mechanism among 5-HT derived neurotoxins and suggest that tryptamine-4,5-dione and/or its glutathione conjugate would cause neuronal damage, if they are formed in vivo.

Risk of dementia among relatives of Alzheimer's disease patients in the MIRAGE study: What is in store for the oldest old?

Despite recent advances in the molecular genetics of Alzheimer's disease (AD), several fundamental questions concerning risk of illness are unresolved, namely, if Mendelian factors account for the incidence of the disease, and if AD is an inevitable consequence of the aging process. This study was designed to address these issues and other aspects of familial aggregation of the disorder. A consecutive sample of 1,694 patients who met criteria for a diagnosis of probable or definite AD were ascertained in 13 centers participating in the Multi-Institutional Research in Alzheimer Genetic Epidemiology (MIRAGE) project. Lifetime risk and age at onset of AD among various strata of 12,971 first-degree relatives was estimated using survival analysis procedures. The lifetime risk of AD in first-degree relatives was 39.0% +/- 2.1% by age 96 years. Age-specific risk of AD declined after age 90 and the data set included 61 apparently unaffected persons who survived to age 96 without becoming demented. Female relatives had a higher risk of AD than male relatives at all ages. By age 80, children of conjugal AD couples had a cumulative risk of 54%, 1.5 times greater than the sum of the risks to children having affected mothers or fathers, and nearly 5 times greater than the risk to children having normal parents. Children of affected fathers had a cumulative risk that was 1.4 times the corresponding risk to children of affected mothers. Risk assessment in early-onset and late-onset families, using various strategies for determining the age cut-off, yielded contradictory results. These data suggest the following: (1) the lifetime risk among relatives does not support a simple autosomal dominant inheritance pattern of disease; (2) women are innately more susceptible to AD than men; (3) the proportion of hereditary cases may be higher in men than women; (4) distinction between early- onset and late-onset forms of AD has little meaning in the absence of a biological marker; (5) the risk of AD decreases after age 90; and (6) AD therefore may not be an inevitable concomitant of the aging process, a conclusion that has profound implications for basic and applied AD research. The age- and sex-specific lifetime risks derived from this study are sufficiently robust to be a reliable source of information for counseling relatives of AD patients.

Allele epsilon 4 of apolipoprotein E shows a dose effect on age at onset of Pick disease

Pick disease is a rare progressive dementing illness characterized by severe atrophy of the frontal and temporal lobes. Clinically, Pick disease may be difficult to distinguish from Alzheimer disease (AD). The fact that Pick disease is often familial, and the evidence suggesting that the epsilon 4 allele of apolipoprotein E (ApoE) is a risk factor for AD and possibly other dementias, prompted us to study ApoE isoforms in Pick disease. ApoE genotypes were evaluated in an autopsy series of 21 AD and 12 Pick cases and compared with published data for a large group of adults participating in the Framingham Study. The distributions of ApoE genotypes in the AD and Pick patients and the controls were significantly different from one another. The frequency of epsilon 4 was 50.0, 20.0, and 13.6% in these respective groups. Linear regression analysis showed that the number of epsilon 4 alleles was inversely related to age at onset of Pick disease (P < 0.03) and accounted for 40% of the variation in age at onset. These results suggest that epsilon 4 may be a susceptibility factor for dementia and not specifically for AD. Experiments using a monoclonal antibody against ApoE suggest that neurons and Pick bodies are immunoreactive with ApoE. The dose effect of the epsilon 4 allele on age at onset of dementias other than AD and the association of ApoE immunoreactivity with neurons and Pick bodies support a broader role for ApoE in the pathogenesis of neuronal degeneration through interactions with the neuronal cytoskeleton.

Reaching consensus: the process of recommending treatment decisions for Alzheimer's patients

Observational and interview data obtained from nurse caregivers and family members of patients with late-stage Alzheimer's disease were analyzed to explicate the nursing role in advance proxy planning. A four-phase model, Achieving Consensus: Decision Making to Determine Treatment Options for Patients with Alzheimer's Disease, was developed. Patient decline, family coping, professional development of nursing staff, and nursing unit philosophy were community characteristics found to be important antecedents to the process of reaching consensus. Achieving consensus constructs included interactive process components of patient, family, and staff adjustment, caring, and knowing. Timing and trust were influential catalysts to family and staff readiness factors for achieving consensus. Outcomes were the advice provided by staff and the family conference where treatment options were determined. Consequences included the advance proxy plan and patient care.

Effect of prenatal malnutrition on release of monoamines from hippocampal slices

The effect of prenatal protein malnutrition on release of monoamine neurotransmitters, their precursors and metabolites, from hippocampal slices was investigated in 15, 30, 90 and 220 days old male rats. The release of dopamine and its metabolites, tryptophan, and 5-hydroxyindoleacetic acid from hippocampal slices of malnourished rats was greater than release from control slices at all ages studied. Malnutrition also significantly increased the release of normetanephrine but only in the 220 day age group. Potassium-induced depolarization increased release of tyrosine, normetanephrine and 5-hydroxyindoleacetic acid less from slices of malnourished than from control rats. The release of norepinephrine, normetanephrine, serotonin and 5-hydroxyindoleacetic acid increased significantly with age while the release of tyrosine, 3,4-dihydroxyphenylacetic acid and homovanillic acid decreased significantly with age. Age was also significantly associated with the effectiveness of potassium-induced depolarization in increasing release of tyrosine, norepinephrine, normetanephrine, tryptophan, serotonin and 5-hydroxyindoleacetic acid.

Circadian locomotor activity and core-body temperature rhythms in Alzheimer's disease

Sleep-wake cycle disturbances suggest that circadian rhythms may be disrupted in patients with Alzheimer's disease (AD). In this study, we examined the circadian rhythms of core-body temperature and locomotor activity in 28 patients with probable AD and 10 healthy controls. AD patients had higher percent nocturnal activity than controls, corresponding to the clinical picture of fragmented sleep. The amplitude of the activity cycle in the AD patients was lower than that of controls and the acrophase of this cycle in AD patients was 4.5 h later. There was no difference in the amplitude of the core-body temperature circadian rhythm, but AD patients had delayed temperature acrophases. A subgroup of AD patients with large mean time differences between the acrophases of their activity and temperature cycles had lower temperature amplitudes and greater activity during the night. These findings suggest that a subgroup of AD patients with impaired endogenous pacemaker function may have a diminished capacity to synchronize the rhythm of core-body temperature with the circadian cycle of rest-activity. This circadian rhythm dysfunction may partly explain the fragmented nocturnal sleep exhibited by these patients.

Effect of seizures on progression of dementia of the Alzheimer type

A survey of institutionalized patients with clinical diagnosis of probable dementia of the Alzheimer type (DAT) indicated that 21% of patients developed seizures after the onset of DAT. Of the total of 27 patients, 11 developed seizures at home and 16 after institutionalization. In 9 of 11 patients (82%), who suffered the initial seizure at home, the patients' condition suddenly worsened and required long-term care admission within 6 months of the seizure onset. Language function declined significantly more rapidly in 5 patients with seizures than in controls matched by age and duration of DAT.