Young-onset dementia and the need for specialist care: a national and international perspective

OBJECTIVES

Receiving a timely and accurate diagnosis and gaining access to age-appropriate support for younger people living with dementia (YPD) remains a challenge both in the UK and internationally because the focus of most dementia services is primarily upon the needs of older people. The political case to improve services for YPD depends upon the establishment of an understanding of the clinical symptoms, an unequivocal evidence base about need and an accurate evaluation of the size of the population affected. This short report assesses the evidence base from international studies regarding service design and delivery. The goal is to raise awareness, advance best practice and galvanise the international community to address the serious underfunding and underprovision of care for this marginalised group.

CONCLUSION

The current evidence suggests that there are universal problems, regardless of continent, with delays to diagnosis and poor understanding of optimum models for service provision and long-term care.

[The unresponsive wakefulness syndrome: Dutch perspectives]

The unresponsive wakefulness syndrome (UWS), formerly known as the vegetative state, is one of the most dramatic outcomes of acquired brain injury. Patients with UWS open their eyes spontaneously but demonstrate only reflexive behavior; there are no signs of consciousness. Research shows that, for years now, the Netherlands has the world's lowest documented prevalence of UWS. Unfortunately, this small group of vulnerable patients does not receive the care it needs. Access to specialized rehabilitation is limited, misdiagnosis rates are high and a substantial number of UWS patients receive life-prolonging treatment beyond chances of recovery, despite a framework allowing for discontinuation of such treatment once recovery of consciousness has become unlikely. By comparing data from 2012 with that of 2003, this paper illustrates the current situation and outlook for UWS patients in the Netherlands and makes recommendations for the optimization of treatment and care, as well as for future research.

Antipsychotic drug prescription rates among Dutch nursing homes: the influence of patient characteristics and the dementia special care unit

OBJECTIVES

To assess the differences in antipsychotic drug prescription rates in residents with dementia in dementia special care units (SCUs) of Dutch nursing homes, considering the differences in patient characteristics.

METHOD

As part of the Waalbed-II study, the data on antipsychotic drug use in 290 patients were collected and the Global Deterioration Scale (GDS) stage, type of dementia and behaviour (Cohen-Mansfield Agitation Inventory (CMAI)) were measured in 14 SCUs in nine nursing homes. A multilevel logistic regression model was used to assess the difference in antipsychotic drug prescription rates between dementia SCUs adjusted for age, gender, GDS stage, type of dementia and CMAI factor scores.

RESULTS

Two hundred and ninety residents met the inclusion criteria. Thirty-two per cent were prescribed an antipsychotic drug. Antipsychotic drugs were more often prescribed in patients with physically aggressive and non-aggressive behaviour and in patients with mixed dementia (vascular/Alzheimer's) than in patients with other types of dementia. Antipsychotic drug prescriptions significantly differed among the dementia SCUs. The odds of antipsychotic drug use for patients in the SCU with the highest prevalence of drug use were 2.76 (95% confidence interval (CI) 1.14-6.69) times as high as for the SCU with the lowest prevalence of drug use, taking the patient characteristics into account.

CONCLUSION

Antipsychotic drug use in nursing home residents with dementia is not only predicted by the type of dementia and patient behaviour, but it is independently associated with the dementia SCU at which the patient resides. This result indicates that antipsychotic drugs are not only prescribed for their clinical indications (agitation/aggression) but are associated with environmental factors that may reflect a specific nursing home prescribing culture.

Diagnostic accuracy of Parkinson's disease and atypical parkinsonism in nursing homes

INTRODUCTION

Management of Parkinson's disease (PD) and atypical parkinsonism in nursing homes depends on a timely and accurate diagnosis. However, little is known about the diagnostic accuracy of these parkinsonian syndromes in nursing homes. We examined this issue in a large group of Dutch nursing home residents.

METHODS

Twelve large nursing home organizations in the Netherlands accounting for 100 nursing homes with a total population of 5480 residents participated. Residents with PD or atypical parkinsonism were identified according to their nursing home medical chart diagnosis. Additionally, local pharmacists provided a list of all residents using antiparkinson medication. We compared the admission diagnosis to a clinical diagnosis made in the study, based upon interview and detailed neurological examination by movement disorders experts. Diagnoses were based on accepted clinical criteria for PD and atypical parkinsonism.

RESULTS

In the total population of 5480 residents, 258 had previously been diagnosed with a form of parkinsonism according to their medical record. In 53 of these residents (20.5%) we changed or rejected the diagnosis. Specifically, we found no parkinsonism in 22 of these 53 residents (8.5% of all patients with suspected parkinsonism). In the remaining 31 residents (12%), we established a new diagnosis within the parkinsonian spectrum.

CONCLUSIONS

In a large population of Dutch nursing home residents, 20% of diagnoses within the parkinsonian spectrum were inaccurate. Almost 9% of residents had inadvertently received a diagnosis of parkinsonism. Better recognition of parkinsonism in nursing homes is important, because of the consequences for management and prognosis.

The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies

One of the worst outcomes of acquired brain injury is the vegetative state, recently renamed 'unresponsive wakefulness syndrome' (VS/UWS). A patient in VS/UWS shows reflexive behaviour such as spontaneous eye opening and breathing, but no signs of awareness of the self or the environment. We performed a systematic review of VS/UWS prevalence studies and assessed their reliability. Medline, Embase, the Cochrane Library, CINAHL and PsycINFO were searched in April 2013 for cross-sectional point or period prevalence studies explicitly stating the prevalence of VS/UWS due to acute causes within the general population. We additionally checked bibliographies and consulted experts in the field to obtain 'grey data' like government reports. Relevant publications underwent quality assessment and data-extraction. We retrieved 1032 papers out of which 14 met the inclusion criteria. Prevalence figures varied from 0.2 to 6.1 VS/UWS patients per 100 000 members of the population. However, the publications' methodological quality differed substantially, in particular with regards to inclusion criteria and diagnosis verification. The reliability of VS/UWS prevalence figures is poor. Methodological flaws in available prevalence studies, the fact that 5/14 of the studies predate the identification of the minimally conscious state (MCS) as a distinct entity in 2002, and insufficient verification of included cases may lead to both overestimation and underestimation of the actual number of patients in VS/UWS.

[Stroke rehabilitation in nursing homes: intensity of and motivation for physiotherapy]

INTRODUCTION

Stroke is a frequent and potential invalidating disease, of which recovery can be improved by rehabilitation. In The Netherlands old and frail stroke patients are rehabilitated in nursing homes. Probably, the intensity of and motivation for physiotherapy are important for successful discharge. The aim was to determine (1) therapy intensity of and motivation for physical therapy of geriatric stroke patients (2) its correlates and (3) the effect on discharge destination.

METHODS

Data were obtained from the 'GRAMPS'-study, a longitudinal observational study of stroke rehabilitation in 15 Dutch nursing homes. Direct time spent on physiotherapy was registered during admission. Motivation was measured by the Pittsburgh Rehabilitation Participation Scale (PRPS). Data of 84 patients were analysed using uni- and multivariate regression analysis.

RESULTS

Patients received an average 109 min of physiotherapy per week. 69 patients (82%) were good motivated for physiotherapy (had all PRPS scores 4 or higher). Therapy intensity was positively associated with the presence of a partner and good motivation. No significant independent variables of motivation were found. Therapy-intensity was positively related to discharge to prior living situation.

CONCLUSION

Intensity of physiotherapy of stroke rehabilitation is an independent variable of successful discharge and is higher when the patient has a partner or is better motivated. These findings stress the importance of high motivation and therapy intensity in geriatric stroke rehabilitation.

Time to diagnosis in young-onset dementia as compared with late-onset dementia

BACKGROUND

The extent to which specific factors influence diagnostic delays in dementia is unclear. Therefore, the aim of the present study was to compare duration from symptom onset to diagnosis for young-onset dementia (YOD) and late-onset dementia (LOD) and to assess the effect of age at onset, type of dementia, gender, living situation, education and family history of dementia on this duration.

METHOD

Data on 235 YOD and 167 LOD patients collected from caregivers from two prospective cohort studies were used. Multiple linear regression analysis was performed.

RESULTS

The duration between symptom onset and the diagnosis of YOD exceeded that of LOD by an average of 1.6 years (2.8 v. 4.4 years). Young age and being diagnosed with frontotemporal dementia were related to increases in the time to diagnosis. Subjects with vascular dementia experienced shorter time to diagnosis.

CONCLUSIONS

There is a need to raise special awareness of YOD to facilitate a timely diagnosis.

[Refusal of food and fluids of a psychiatric patient in order to hasten death: obstacles for patient, family and care-team]

In this case-report we present a patient with a psychiatric history of a chronic depressive disorder. After a period of several years of ambivalence, he decided to refuse nutrition and hydration because he--in the words of the Royal Dutch Medical Association--was "suffering from life". There was no request for euthanasia or physician assisted suicide. His first attempt, that lasted six weeks, did not result in his death. A second attempt, four months later, ended successfully. We describe the pitfalls that the patient, his family and the professional caregivers faced in both trajectories. The premorbid psychiatric disorder with polypharmacy and several psychotropic drugs as a result, the enormous complaints of thirst, the role of his wife and the dilemmas faced by the professionals made this case very complex. These issues make such cases very challenging for professional teams that have to provide good palliative care.

Three-year prevalence of healthcare-associated infections in Dutch nursing homes

From November 2007 for a period of three years (2007-2009), we conducted an annual one-day prevalence study of healthcare-associated infections (HAIs) among nursing home residents in the Nijmegen region of The Netherlands. In the absence of national HAI definitions applicable to the nursing home setting, we used modified definitions based on US Centers for Disease Control and Prevention criteria for bloodstream infection, lower respiratory tract infection, bacterial conjunctivitis, and gastroenteritis. For the surveillance of urinary tract infection (UTI), criteria established by the Dutch Association of Elderly Care Physicians were used. Resident characteristics were recorded and data collection was performed by the attending elderly care physicians. For the three-year period, 1275, 1323, and 1772 nursing home residents were included, resulting in a prevalence of HAIs of 6.7%, 7.6% and 7.6%, in 2007, 2008 and 2009, respectively. The demographics with respect to age (mean 81 years) and sex (31% men, 69% women) were almost identical in all three years. UTI was the most prevalent HAI with 3.5%, 4.2%, and 4.1% respectively. Most HAIs occurred among residents of rehabilitation units. The prevalence of HAIs varied by nursing home (range: 0.0-32.4%). We present the results of the first prevalence study of HAIs in Dutch nursing homes. Point prevalence studies of HAIs, as part of a quality improvement cycle, are an important cornerstone of infection control programmes in nursing homes, allowing us to further increase patient safety efforts in this setting.

Determinants of quality of life in nursing home residents with dementia

AIMS

The goal of this study is to assess the relationship between quality of life (QoL), neuropsychiatric symptoms (NPS), psychotropic drug use (PDU) and patient characteristics in a large group of nursing home residents with dementia.

METHODS

This cross-sectional observational study included 288 individuals with dementia who reside in 14 special care units in 9 nursing homes. The following measures were used: the Qualidem scale to assess QoL, the Neuropsychiatric Inventory-Nursing Home version, the Global Deterioration Scale (GDS), the Severe Impairment Battery-short version, an Activities of Daily Living scale and PDU. Associations between QoL and NPS were examined using multivariate linear regression models with corrections for potential covariates.

RESULTS

The average age of the residents was 84 years (SD = +/-7). Agitation, depression, psychosis, psychomotor agitation and psychotropic drugs were independently associated with poor QoL. In patients with mild to moderately severe dementia (GDS 4-6), NPS, PDU and cognitive impairment explained almost half of the variance in QoL scores. Agitation and depression were particularly strong predictors of poor QoL. In patients with severe dementia (GDS 7), agitation, depression, psychosis and cognitive impairment were associated with poor QoL.

CONCLUSIONS

NPS, cognition and PDU independently impair QoL for patients in both the moderate and advanced stages of dementia. These results challenge existing pharmacological intervention strategies and highlight the need for psychosocial interventions in the treatment of NPS.

Validity of the Severe Impairment Battery Short Version

BACKGROUND

Efficient neuropsychological tests are needed to measure cognitive impairment in moderate to severe dementia.

OBJECTIVE

To examine construct validity of the Severe Impairment Battery Short Version (SIB-S) in nursing home patients with moderate to severe dementia, and to examine potential floor effects for the SIB-S.

METHODS

Cross-sectional comparison of cognitive measures, dementia severity and functional dependency.

RESULTS

A total of 290 patients were included 264 of whom had complete SIB-S protocols. Internal consistency of the SIB-S was very high (Cronbach alpha = 0.97). Principal-component analysis produced three factors, the first of which explained more than 50% of common score variance. Semantic memory items loaded highly on the first factor. Total SIB-S scores were associated with cognitive impairment (SIB-S--Mini Mental State Examination (MMSE) rho = 0.91, p<0.001), and with functional dependency (SIB-S--ADL scale rho = -0.61, p<0.001). SIB-S total scores differentiated between dementia stages as measured with the Global Deterioration Scale (F = 164.6; df 3,260, p<0.001). Comparisons of SIB-S total score variance across patients with moderate to severe dementia and patients with below or above average Mini Mental State Exam scores indicate an absence of large floor effects.

CONCLUSION

In this first study examining an independently administered SIB-S, the scale proved to be a homogeneous and valid measure of cognitive impairment. The SIB short version can be used to assess moderately to severely demented patients, who may find it difficult to complete traditional, lengthier neuropsychological tests.

Prognosis and vascular co-morbidity in dementia a historical cohort study in general practice

BACKGROUND

Disease management of dementia in general practice (GP) is hampered by a lack of data on the prognosis of dementia.

AIM

To gain more insight into the life expectancy of and the effects of cardiovascular and cerebrovascular co-morbidity in dementia patients in GP.

DESIGN OF STUDY

Historical cohort.

SETTING

4 general practices in Nijmegen, The Netherlands.

POPULATION

All patients in these practices participating in the Continuous Morbidity Registration (CMR).

METHODS

The patient cohort was diagnosed with dementia between January 1st 1985 and December 31st 2002. The control cohort consisted of patients matched one-to-one with demented patients on age, sex, and socio-economic status. Cardiovascular and cerebrovascular co-morbidity was studied from 5 years before the diagnosis of dementia till the endpoints of data collection.

RESULTS

251 couples of patients and controls were formed (79 men, 172 women, mean age 81.4+/-7.0 years). The median life expectancy after diagnosis was 2.3 years for the dementia patients, and 3.7 years for the controls. Median time from diagnosis till nursing home placement was 1.4 years. Cerebrovascular and cardiovascular morbidity preceding dementia diagnosis decreased survival of cases with dementia with a relative risk of 1.54 (95%CI: 1.13-2.09) and in controls with a relative risk of 1.91 (95%CI: 1.48-2.46). Obesity was associated with a lower risk of dementia (RR=0.77 (95%-CI 0.63-0.94)). Hypertension and obesity diagnosed after the dementia diagnosis were significantly associated with an increase in survival.

CONCLUSION

In general practice, the diagnosis of dementia is made at a late stage, when patients will continue to live at home only for a short time. Moreover, life expectancy at diagnosis is very limited and prognosis is furthermore negatively influenced by preceding cardio- and cerebrovascular co-morbidity.

[Are psychotropic drugs too frequently prescribed in Dutch nursing homes?]

In 1993 Ribbe en Hertogh published a paper in which they expressed their concern about the high prevalence of psychotropic drug use in Dutch nursing homes. Since then, this situation does not seem to have been changed significantly. Recent figures from psychotropic drug use in patients with dementia show prevalence rates of over 60%. The Dutch government decided to choose the prevalence of psychotropic drug use as an indicator of the quality of care and invested in a specific improvement project that aims to reduce psychotropic drug use among nursing home patients. There is a small body of evidence from international research that antipsychotics safely can be reduced without a rise in problem behaviours. In combination with the limited effectiveness and the risk of stroke and increased mortality, the question raises whether these agents should be prescribed at all at least for patients with dementia. A recent study from the UK however, found a significant decrease of antipsychotic drug use by heavily investing in all kinds of person-centered care skills of the nursing staff. These findings underscore the necessity of investing in the caregivers of nursing homes to be able to cope with the complex problems they are faced with.

[Dementia: the importance of psychosocial interventions]

The number of people suffering from dementia in The Netherlands is expected to rise from 175,000 in 2006 to 400,000 by the year 2050. Stella Braam recently wrote a book in which she described the experiences of her father, a former psychologist with the attitudes and knowledge of professionals concerning communication and coping with dementia, when he became dement himself. She reports that hardly anyone actually listened to the emotions and wishes of her father. Coping with dementia constitutes a major challenge to society. A working-group of the Dutch Institute for Healthcare Improvement CBO recently advised psychological approaches as the first-line treatment for the neuropsychiatric symptoms of dementia; however, they decided not to give concrete guidelines because of the lack of evidence. A study of the literature reveals that the effects of psychosocial interventions are certainly promising even though the evidence is weak. Investment in more research in this field and immediate implementation of the existing knowledge by caregivers and professional workers are recommended.

[Efficacy and adverse reactions of antipsychotics for neuropsychiatric symptoms in dementia: a systematic review]

OBJECTIVE

To assess the efficacy and adverse reactions of typical and atypical antipsychotics in the treatment of neuropsychiatric symptoms in dementia, and to examine the evidence for the cerebrovascular events warning for atypical antipsychotics.

DESIGN

Systematic review.

METHOD

Using Medline, Cinahl, PsyclNFO, Embase and the Cochrane central register of controlled trials (1980-2005), double-blind randomized controlled trials with intention-to-treat analysis were selected, which evaluated efficacy and adverse reactions of antipsychotics in the treatment of neuropsychiatric symptoms in dementia. The studies underwent a standardised validity assessment.

RESULTS

After screening 950 studies, 14 studies on the effect of haloperidol, risperidone, olanzapine, quetiapine, tiapride, loxapine and perphenazine were selected. In 7 out of 10 studies, haloperidol, risperidone and olanzapine appeared to be more effective than placebo in the treatment of aggression and psychosis. Direct comparison between typical and atypical antipsychotics revealed no statistically significant difference. The most common adverse reactions were extrapyramidal symptoms and somnolence. These adverse reactions were less frequent with low-dose risperidone than with haloperidol or olanzapine, but risperidone and olanzapine were found to be associated with a higher risk of cerebrovascular events in two studies.

CONCLUSION

The efficacy of typical and atypical antipsychotics is comparable, but only low-dose risperidone seems to be associated with fewer (extrapyramidal) side effects. The adverse reactions are inadequately described in the published data and consequently the warning of an increased risk of mortality could not be confirmed.

[Prevalence of behavioural problems in a group of demented nursing home patients]

Behavioural problems in dementia are a burden for patients and caregivers and are often the main reason for admission to a nursing home. Research on the prevalence of behavioural problems is scarce. In this study the prevalence of behavioural problems was estimated in nursing home patients with dementia. In 59 demented patients the Neuropsychiatric Inventory (NPI-NH) and the Cohen-Mansfield Agitation Inventory were used to measure behavioural problems over the last two weeks. Behavioural problems were present in about 85% of the study group. Using the NPI-NH aggression/agitation and apathy were present in almost 40% of the patients. Delusions, hallucinations, depression and anxiety were present in 10-15% of the patients. Using the CMAI cursing/verbal aggression, restlessness, complaining, negativism, and mannerisms were prevalent in 30%-50% of the patients. Larger studies on the prevalence of problem behaviour and possibly influencing factors are necessary.

Prevalence and characteristics of patients in a vegetative state in Dutch nursing homes

OBJECTIVES

To establish the prevalence of vegetative state in Dutch nursing homes, describe the patient characteristics, and highlight the possible influence of medical decisions at the end of life.

DESIGN

A cross-sectional survey. The vegetative state was defined according to the Multi Society Task Force on PVS. All Dutch nursing homes were approached to provide data on patients in a vegetative state. In cases of doubt, the researcher discussed the diagnosis with the patient's physician and, if necessary, examined the patient. Information on patients in a vegetative state in care between 2000 and September 2003 and end of life decisions for them were also recorded.

RESULTS

All nursing homes and physicians participated. After assessment of 12 doubtful patients, 32 met the criteria of vegetative state lasting longer than one month, a prevalence of 2/1,000,000. Of these, 30 patients' data were analysed: age 9-90 years; 73% female; duration of vegetative state 2 months-20 years (26 surviving >1 year, 13 >5 years). Stroke was the commonest cause. Between 2000 and September 2003, there were 76 patients in a vegetative state in care of whom 34 died of complications and nine after withdrawal of artificial nutrition and hydration.

CONCLUSIONS

The prevalence of vegetative state in Dutch nursing homes has been established for the first time. The figures are lower than suggested in the literature. The study included a heterogeneous group of patients, of which a substantial number survived for many years. The results cannot be explained by a policy of systematically withdrawing artificial nutrition and hydration.

[The final phase of dementia in a group of nursing home patients: prevalence and characteristics]

There is scant literature about patients in the final phase of dementia. Uniform terminology and operational definition of the final phase of dementia is lacking. Furthermore, it is difficult to monitor these patients because existing assessment scales face bottom- or ceiling effects in this population. The aim of this study was to assess the prevalence and the characteristics of patients in the final phase of dementia in a group of 210 Dutch nursing home patients with dementia. Stage 7 of the Global Deterioration Scale of Reisberg et al. was used to operationally define the final phase of dementia. All patients were scored on a self-constructed assessment scale. Furthermore, treatment aspects and advance directives were registered.